Provider Demographics
NPI:1841904851
Name:TOLAND, ELLORA
Entity type:Individual
Prefix:
First Name:ELLORA
Middle Name:
Last Name:TOLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLORA
Other - Middle Name:
Other - Last Name:MCCORKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:313 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LESLIE
Mailing Address - State:MI
Mailing Address - Zip Code:49251-9484
Mailing Address - Country:US
Mailing Address - Phone:517-662-9481
Mailing Address - Fax:
Practice Address - Street 1:126 SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3558
Practice Address - Country:US
Practice Address - Phone:734-219-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MI6451022753101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor