Provider Demographics
NPI:1578365854
Name:TOMBERLIN, MARK JR (LPC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TOMBERLIN
Suffix:JR
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1257 COMMERCIAL DR SW STE A
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5991
Mailing Address - Country:US
Mailing Address - Phone:770-285-6049
Mailing Address - Fax:
Practice Address - Street 1:1257 COMMERCIAL DR SW STE A
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5991
Practice Address - Country:US
Practice Address - Phone:770-285-6049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC15605101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional