Healthcare Provider Details

I. General information

NPI: 1548644107
Provider Name (Legal Business Name): MARIAH FUNDERBURG LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 129
NEEDLES CA
92363-0129
US

IV. Provider business mailing address

PO BOX 129
NEEDLES CA
92363-0129
US

V. Phone/Fax

Practice location:
  • Phone: 442-214-4137
  • Fax: 442-244-8566
Mailing address:
  • Phone: 442-214-4137
  • Fax: 442-244-8566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT154823
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: