Provider Demographics
NPI:1750919577
Name:REISS-TOLLIVER, KATHERYN (MS)
Entity type:Individual
Prefix:
First Name:KATHERYN
Middle Name:
Last Name:REISS-TOLLIVER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 KNICKERBOCKER RD APT 1
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2153
Mailing Address - Country:US
Mailing Address - Phone:201-724-8036
Mailing Address - Fax:
Practice Address - Street 1:32 COLEMAN TER
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-2620
Practice Address - Country:US
Practice Address - Phone:201-724-8036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Y00000X
NJ18KT00297600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist