Provider Demographics
NPI:1407247000
Name:PRINCE KOROBOV, KIMBERLY ANN (MA, MDIV, LPC, NCC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:PRINCE KOROBOV
Suffix:
Gender:F
Credentials:MA, MDIV, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 TANNER ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3207
Mailing Address - Country:US
Mailing Address - Phone:678-346-5027
Mailing Address - Fax:770-834-1865
Practice Address - Street 1:309 TANNER ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3207
Practice Address - Country:US
Practice Address - Phone:678-346-5027
Practice Address - Fax:770-834-1865
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional