Provider Demographics
NPI:1942775515
Name:TOLLIVER, OLLIE MENYETTA (PTA)
Entity Type:Individual
Prefix:
First Name:OLLIE
Middle Name:MENYETTA
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12609 PANORAMA DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7075
Mailing Address - Country:US
Mailing Address - Phone:601-672-6678
Mailing Address - Fax:
Practice Address - Street 1:300 CROWN POINTE BLVD
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-1160
Practice Address - Country:US
Practice Address - Phone:817-757-1224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2095040225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant