Healthcare Provider Details

I. General information

NPI: 1144722356
Provider Name (Legal Business Name): EMILY ROSE TOLLER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2018
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5342 DUDLEY BLVD
MCCLELLAN CA
95652-1012
US

IV. Provider business mailing address

5342 DUDLEY BLVD
MCCLELLAN CA
95652-1012
US

V. Phone/Fax

Practice location:
  • Phone: 916-561-7725
  • Fax:
Mailing address:
  • Phone: 916-561-7725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY.0006509
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: