Provider Demographics
NPI:1760559132
Name:TOLLIVER, DENNIS
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:TOLLIVER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LYNETTE
Other - Middle Name:
Other - Last Name:TOLLIVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6821 W MALDONADO RD
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2679
Mailing Address - Country:US
Mailing Address - Phone:602-682-7584
Mailing Address - Fax:
Practice Address - Street 1:6821 W MALDONADO RD
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2679
Practice Address - Country:US
Practice Address - Phone:602-682-7584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3936385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ717697OtherAHCCCS