Basic Information
| Provider Information | |||||||||
| NPI: | 1982749693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUNDERBURG | ||||||||
| FirstName: | CAROLIN | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SSW, BA, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7245 E SOUTHGATE DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164277141 | ||||||||
| FaxNumber: | 9164277122 | ||||||||
| Practice Location | |||||||||
| Address1: | 7245 E SOUTHGATE DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164277141 | ||||||||
| FaxNumber: | 9164277122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 11/28/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 103353 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0005222007 | 01 | CA | BABY JOHN'S BIRTHDATE | OTHER |