Basic Information
| Provider Information | |||||||||
| NPI: | 1477073377 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOLLE | ||||||||
| FirstName: | MACK | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CAADE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 508 S 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917233012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269748123 | ||||||||
| FaxNumber: | 6269748198 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 E COOLEY DR | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803705 | ||||||||
| FaxNumber: | 9095803747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2017 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1913097 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.