Provider Demographics
NPI:1699029934
Name:FUNDORA, GLADYS MARIA (LMHC, BCBA)
Entity type:Individual
Prefix:
First Name:GLADYS
Middle Name:MARIA
Last Name:FUNDORA
Suffix:
Gender:F
Credentials:LMHC, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12917 SW 133RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-6906
Mailing Address - Country:US
Mailing Address - Phone:305-731-4067
Mailing Address - Fax:
Practice Address - Street 1:12917 SW 133RD TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-6906
Practice Address - Country:US
Practice Address - Phone:305-731-4067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-08
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
BCBA19-38877103K00000X
FLMH14818101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health