Healthcare Provider Details

I. General information

NPI: 1740870450
Provider Name (Legal Business Name): TIARAH MARIE FUNDERBURK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 YORK RD
BALTIMORE MD
21212-3610
US

IV. Provider business mailing address

1003 W 7TH ST STE 500
FREDERICK MD
21701-8512
US

V. Phone/Fax

Practice location:
  • Phone: 301-345-1022
  • Fax:
Mailing address:
  • Phone: 301-345-1022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number26353
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: