Provider Demographics
NPI:1700276623
Name:HUNNICUTT-FERGUSON, KALLIO (PHD)
Entity Type:Individual
Prefix:
First Name:KALLIO
Middle Name:
Last Name:HUNNICUTT-FERGUSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 EXECUTIVE PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2206
Mailing Address - Country:US
Mailing Address - Phone:404-778-7777
Mailing Address - Fax:
Practice Address - Street 1:12 EXECUTIVE PARK DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2206
Practice Address - Country:US
Practice Address - Phone:404-778-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY0041242084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021253OtherNEW YORK STATE EDUCATION DEPARTMENT, LICENSE IN CLINICAL PSYCHOLOGY
GAPSY004124OtherSTATE OF GEORGIA, STATE BOARD OF EXAMINERS OF PSYCHOLOGISTS
NY94893OtherNEW YORK STATE EDUCATION DEPARTMENT LIMITED PERMIT FOR CLINICAL PSYCHOLOGY