Healthcare Provider Details

I. General information

NPI: 1750461075
Provider Name (Legal Business Name): DR. RAY JOSEPH KUCKLEBURG JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 CENTURY BLVD NE STE A
ATLANTA GA
30345-3399
US

IV. Provider business mailing address

1780 CENTURY BLVD NE STE A
ATLANTA GA
30345-3399
US

V. Phone/Fax

Practice location:
  • Phone: 404-636-6607
  • Fax: 404-315-9744
Mailing address:
  • Phone: 404-636-6607
  • Fax: 404-315-9744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number414
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: