Provider Demographics
NPI:1548486152
Name:FUNDERBURG, DYNATA CHARLES (MA)
Entity type:Individual
Prefix:MRS
First Name:DYNATA
Middle Name:CHARLES
Last Name:FUNDERBURG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1060
Mailing Address - Country:US
Mailing Address - Phone:708-647-6426
Mailing Address - Fax:708-647-6233
Practice Address - Street 1:806 MAPLE RD
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1060
Practice Address - Country:US
Practice Address - Phone:708-647-6426
Practice Address - Fax:708-647-6233
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities