Provider Demographics
NPI:1902151210
Name:JOLLY, DEBRA FUNDERBURK (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:FUNDERBURK
Last Name:JOLLY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MRS
Other - First Name:DEBRA
Other - Middle Name:FUNDERBURK
Other - Last Name:PELHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:14408 PLANTERS KNOB LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-7847
Mailing Address - Country:US
Mailing Address - Phone:704-807-0760
Mailing Address - Fax:
Practice Address - Street 1:14408 PLANTERS KNOB LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-7847
Practice Address - Country:US
Practice Address - Phone:704-807-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3935235Z00000X
SC786235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411800Other2002 MEDICAID PROVIDER (OUTDATED)