Provider Demographics
NPI:1063555266
Name:TOMORI, ROLAKE O (PSYD)
Entity type:Individual
Prefix:DR
First Name:ROLAKE
Middle Name:O
Last Name:TOMORI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6181
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30065-0181
Mailing Address - Country:US
Mailing Address - Phone:916-912-8906
Mailing Address - Fax:
Practice Address - Street 1:1551 JULIETTE DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-1509
Practice Address - Country:US
Practice Address - Phone:678-639-2257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003452103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical