Healthcare Provider Details

I. General information

NPI: 1609909753
Provider Name (Legal Business Name): DWIGHT DAVID TOLLIVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 E BROAD ST STE 301
COLUMBUS OH
43215-4037
US

IV. Provider business mailing address

620 E BROAD ST STE 301
COLUMBUS OH
43215-4037
US

V. Phone/Fax

Practice location:
  • Phone: 614-914-6690
  • Fax: 614-745-3344
Mailing address:
  • Phone: 614-914-6690
  • Fax: 147-453-3446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6578
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6578
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: