Healthcare Provider Details

I. General information

NPI: 1508755018
Provider Name (Legal Business Name): TOLLER ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9211 STUART LN
CLINTON MD
20735-2712
US

IV. Provider business mailing address

2232 E MONUMENT ST
BALTIMORE MD
21205-2431
US

V. Phone/Fax

Practice location:
  • Phone: 301-863-3600
  • Fax: 301-856-6218
Mailing address:
  • Phone: 667-207-3552
  • Fax: 443-885-9778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: WALTER LEWIS TOLLER
Title or Position: OWNER
Credential:
Phone: 667-207-3552