Provider Demographics
NPI:1083041347
Name:FUNSTON, CYNTHIA MARIE
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:MARIE
Last Name:FUNSTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:MARIE
Other - Last Name:ORTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:335 FOUR MILE RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-4506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3488
Practice Address - Country:US
Practice Address - Phone:843-903-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2806235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist