Healthcare Provider Details

I. General information

NPI: 1417448390
Provider Name (Legal Business Name): AMANDA TOLBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA TOLBERT

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2613 JOHN BOURG DR
PLAINFIELD IL
60586-6940
US

IV. Provider business mailing address

2613 JOHN BOURG DR
PLAINFIELD IL
60586-6940
US

V. Phone/Fax

Practice location:
  • Phone: 708-309-0411
  • Fax:
Mailing address:
  • Phone: 708-309-0411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: