Provider Demographics
NPI:1720131576
Name:FUNDERBURK, NANNETTE SMITH (PHD, LCMHCS)
Entity type:Individual
Prefix:DR
First Name:NANNETTE
Middle Name:SMITH
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:PHD, LCMHCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 BATTLEGROUND AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-2491
Mailing Address - Country:US
Mailing Address - Phone:336-285-7173
Mailing Address - Fax:336-285-7174
Practice Address - Street 1:3300 BATTLEGROUND AVE STE 304
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2491
Practice Address - Country:US
Practice Address - Phone:336-285-7173
Practice Address - Fax:336-285-7174
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5348101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103431Medicaid