Healthcare Provider Details

I. General information

NPI: 1063555266
Provider Name (Legal Business Name): ROLAKE O TOMORI PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 KENNESAW AVE NW STE 150
MARIETTA GA
30060-7941
US

IV. Provider business mailing address

PO BOX 6181
MARIETTA GA
30065-0181
US

V. Phone/Fax

Practice location:
  • Phone: 470-328-9806
  • Fax:
Mailing address:
  • Phone: 916-912-8906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003452
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: