Healthcare Provider Details

I. General information

NPI: 1558129254
Provider Name (Legal Business Name): DESTINY DONYE LIBRETTE TOLLIVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2024
Last Update Date: 03/09/2024
Certification Date: 03/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 MCHENRY AVE
MODESTO CA
95350-4528
US

IV. Provider business mailing address

3433 W SHAW AVE STE 108
FRESNO CA
93711-3229
US

V. Phone/Fax

Practice location:
  • Phone: 209-758-0825
  • Fax:
Mailing address:
  • Phone: 559-558-4051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: