Provider Demographics
NPI:1447496385
Name:KUNKEL, MARK ALAN (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:KUNKEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 TANNER ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3207
Mailing Address - Country:US
Mailing Address - Phone:678-571-4126
Mailing Address - Fax:
Practice Address - Street 1:309 TANNER ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3207
Practice Address - Country:US
Practice Address - Phone:678-571-4126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-24
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001952103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA331634834AMedicaid