Provider Demographics
NPI:1386247906
Name:FUNDERBURK, DONNA R (MA)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:R
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 HARBOR LN N STE 206
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5120
Mailing Address - Country:US
Mailing Address - Phone:763-559-1640
Mailing Address - Fax:763-559-1617
Practice Address - Street 1:3021 HARBOR LN N STE 206
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5120
Practice Address - Country:US
Practice Address - Phone:763-559-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health