Provider Demographics
NPI:1417448390
Name:TOLBERT, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:TOLBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:TOLBERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2613 JOHN BOURG DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-6940
Mailing Address - Country:US
Mailing Address - Phone:708-309-0411
Mailing Address - Fax:
Practice Address - Street 1:2613 JOHN BOURG DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-6940
Practice Address - Country:US
Practice Address - Phone:708-309-0411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health