MEDICARE: MRS. DONNA R FUNDERBURK MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1386247906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DONNA R FUNDERBURK MA

Provider Business Mailing Address
First Line	:	3021 HARBOR LN N STE 206
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55447-5120
Country	:	US
Telephone Number	:	763-559-1640
Fax Number	:	763-559-1617

Provider Business Practice Location Address
First Line	:	3021 HARBOR LN N STE 206
Second Line	:
City	:	PLYMOUTH
State	:	MN
Zip	:	55447-5120
Country	:	US
Telephone Number	:	763-559-1640
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2020
Last Update Date	:	11/17/2020

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