Provider Demographics
NPI:1972121929
Name:KLOMP, RICHARD WALLACE (LPC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WALLACE
Last Name:KLOMP
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3275 OAK HAMPTON WAY
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5882
Mailing Address - Country:US
Mailing Address - Phone:404-518-4325
Mailing Address - Fax:
Practice Address - Street 1:1810 PEACHTREE INDUSTRIAL BLVD STE 231
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8178
Practice Address - Country:US
Practice Address - Phone:404-518-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003903101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health