Provider Demographics
NPI:1710900964
Name:TOLLISON, CHARLES DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:TOLLISON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 BOILING SPRINGS ROAD
Mailing Address - Street 2:SUITE 2700
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303
Mailing Address - Country:US
Mailing Address - Phone:864-583-0053
Mailing Address - Fax:864-583-0390
Practice Address - Street 1:220 ROPER MTN RD EXT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-295-6399
Practice Address - Fax:864-295-2337
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC293103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q31413Medicare UPIN