Provider Demographics
NPI:1013442854
Name:TOLLER, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:TOLLER
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 1:1011 SE 5TH CT
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-5917
Mailing Address - Country:US
Mailing Address - Phone:786-277-2605
Mailing Address - Fax:
Practice Address - Street 1:1011 SE 5TH CT
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-5917
Practice Address - Country:US
Practice Address - Phone:786-277-2605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-30
Last Update Date:2017-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1851649297103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst