Provider Demographics
NPI:1750461075
Name:KUCKLEBURG, RAY JOSEPH JR
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:JOSEPH
Last Name:KUCKLEBURG
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 CENTURY BLVD NE STE A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3399
Mailing Address - Country:US
Mailing Address - Phone:404-636-6607
Mailing Address - Fax:404-315-9744
Practice Address - Street 1:1780 CENTURY BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3399
Practice Address - Country:US
Practice Address - Phone:404-636-6607
Practice Address - Fax:404-315-9744
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA414103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist