Provider Demographics
NPI:1265250120
Name:TIMBERLAKE, DEMOND JR (NBCHWC)
Entity type:Individual
Prefix:MR
First Name:DEMOND
Middle Name:
Last Name:TIMBERLAKE
Suffix:JR
Gender:M
Credentials:NBCHWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 HARTFORD AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-4234
Mailing Address - Country:US
Mailing Address - Phone:919-608-6823
Mailing Address - Fax:
Practice Address - Street 1:289 S CULVER ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4805
Practice Address - Country:US
Practice Address - Phone:800-516-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
A3399018171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach