Healthcare Provider Details

I. General information

NPI: 1023531795
Provider Name (Legal Business Name): ILEANA PATRICIA TOL LCSW-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W WALKER AVE
ASHEBORO NC
27203-6760
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 110
CONCORD NC
28025-1834
US

V. Phone/Fax

Practice location:
  • Phone: 336-633-7000
  • Fax:
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP011764
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: