Healthcare Provider Details

I. General information

NPI: 1720522428
Provider Name (Legal Business Name): WILLIAM FUNDORA MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E 8TH AVE
HIALEAH FL
33010-4613
US

IV. Provider business mailing address

19413 NW 48TH AVE
MIAMI GARDENS FL
33055-2023
US

V. Phone/Fax

Practice location:
  • Phone: 305-883-5188
  • Fax:
Mailing address:
  • Phone: 786-800-7836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: