MEDICARE: KOLLETTE TOLBERT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1811629033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOLLETTE TOLBERT, LLC

Provider Business Mailing Address
First Line	:	PO BOX 417
Second Line	:
City	:	GANADO
State	:	TX
Zip	:	77962-0417
Country	:	US
Telephone Number	:	361-437-0462
Fax Number	:	361-214-2861

Provider Business Practice Location Address
First Line	:	17350 STATE HIGHWAY 249 STE 220-6454
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77064-1147
Country	:	US
Telephone Number	:	361-238-7355
Fax Number	:	361-214-2861

Authorized Official
Title or Position	:	LPC/CEO
Name	:	KOLLETTE D TOLBERT
Credential	:	LPC
Telephone Number	:	361-437-0462

Provider Enumeration Date	:	06/27/2022
Last Update Date	:	06/27/2022

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