Provider Demographics
NPI:1073949475
Name:POMALES, KWANIKA
Entity Type:Individual
Prefix:
First Name:KWANIKA
Middle Name:
Last Name:POMALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 SUGARLOAF PARKWAY
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043
Mailing Address - Country:US
Mailing Address - Phone:678-697-5793
Mailing Address - Fax:
Practice Address - Street 1:5425 SUGARLOAF PARKWAY
Practice Address - Street 2:SUITE 1101
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043
Practice Address - Country:US
Practice Address - Phone:678-697-5793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2020-10-07
Deactivation Date:2015-11-09
Deactivation Code:
Reactivation Date:2020-10-07
Provider Licenses
StateLicense IDTaxonomies
GALPC006225101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional