Healthcare Provider Details

I. General information

NPI: 1659329274
Provider Name (Legal Business Name): KATHRYN JAYNE STEVENSON FUNDERBURK LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: MISS KATHRYN JAYNE STEVENSON

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 LIBERTY HILL RD SWCMHC/KERSHAW CMHC,
CAMDEN SC
29020-1871
US

IV. Provider business mailing address

215 N MAGNOLIA ST SWCMHC
SUMTER SC
29150-4943
US

V. Phone/Fax

Practice location:
  • Phone: 803-432-5323
  • Fax: 803-713-3978
Mailing address:
  • Phone: 803-775-9364
  • Fax: 803-773-6615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6152
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: