Provider Demographics
NPI:1942798277
Name:TOLLES, HANNAH GAIL
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:GAIL
Last Name:TOLLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13260 CASTLE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1129
Mailing Address - Country:US
Mailing Address - Phone:313-670-1140
Mailing Address - Fax:
Practice Address - Street 1:13260 CASTLE ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1129
Practice Address - Country:US
Practice Address - Phone:313-670-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1741995106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician