Basic Information
Provider Information | |||||||||
NPI: | 1659329274 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FUNDERBURK | ||||||||
FirstName: | KATHRYN | ||||||||
MiddleName: | JAYNE STEVENSON | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LISW-CP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STEVENSON | ||||||||
OtherFirstName: | KATHRYN | ||||||||
OtherMiddleName: | JAYNE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 215 N MAGNOLIA ST | ||||||||
Address2: | SWCMHC | ||||||||
City: | SUMTER | ||||||||
State: | SC | ||||||||
PostalCode: | 291504943 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037759364 | ||||||||
FaxNumber: | 8037736615 | ||||||||
Practice Location | |||||||||
Address1: | 2611 LIBERTY HILL RD | ||||||||
Address2: | SWCMHC/KERSHAW CMHC, | ||||||||
City: | CAMDEN | ||||||||
State: | SC | ||||||||
PostalCode: | 290201871 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8034325323 | ||||||||
FaxNumber: | 8037133978 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6152 | SC | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.