Provider Demographics
NPI:1821591413
Name:TOLLIVER, TYRELL E (ATC)
Entity Type:Individual
Prefix:
First Name:TYRELL
Middle Name:E
Last Name:TOLLIVER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 N CENTER DR NW APT 3B
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8506
Mailing Address - Country:US
Mailing Address - Phone:616-648-5281
Mailing Address - Fax:
Practice Address - Street 1:80 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-2541
Practice Address - Country:US
Practice Address - Phone:616-648-5281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010018702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer