Provider Demographics
NPI:1780341503
Name:TOLBERT, MARVELL DERON (OTA)
Entity type:Individual
Prefix:
First Name:MARVELL
Middle Name:DERON
Last Name:TOLBERT
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8477 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5028
Mailing Address - Country:US
Mailing Address - Phone:800-804-9961
Mailing Address - Fax:352-382-1146
Practice Address - Street 1:16 LAKE HUNTER DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1297
Practice Address - Country:US
Practice Address - Phone:863-577-6063
Practice Address - Fax:352-382-1146
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOTA18447224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant