Provider Demographics
NPI:1053612192
Name:FUNDERBURG, MAYO R II (LADCA)
Entity type:Individual
Prefix:
First Name:MAYO
Middle Name:R
Last Name:FUNDERBURG
Suffix:II
Gender:M
Credentials:LADCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 VESPER LN UNIT L1
Mailing Address - Street 2:
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02554-4394
Mailing Address - Country:US
Mailing Address - Phone:508-228-2689
Mailing Address - Fax:508-228-3613
Practice Address - Street 1:20 VESPER LN UNIT L1
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-4394
Practice Address - Country:US
Practice Address - Phone:508-228-2689
Practice Address - Fax:508-228-3613
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2282101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)