Provider Demographics
NPI:1215077086
Name:TIMBERLAKE, MARK HURT (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:HURT
Last Name:TIMBERLAKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 SHERIDAN RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3714
Mailing Address - Country:US
Mailing Address - Phone:404-325-8512
Mailing Address - Fax:404-325-8733
Practice Address - Street 1:1145 SHERIDAN RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3714
Practice Address - Country:US
Practice Address - Phone:404-325-8512
Practice Address - Fax:404-325-8733
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001107103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist