Healthcare Provider Details

I. General information

NPI: 1508463795
Provider Name (Legal Business Name): JULIANA FUNKUIN FUBUNIWI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIANA FUNKUIN FUBUNIWI

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E PRATT ST FL 8
BALTIMORE MD
21202-3180
US

IV. Provider business mailing address

850 TOWBIN AVE
LAKEWOOD NJ
08701-5928
US

V. Phone/Fax

Practice location:
  • Phone: 410-412-7234
  • Fax:
Mailing address:
  • Phone: 848-216-5355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA1894
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: