Provider Demographics
NPI:1225254279
Name:FUNDERBURG CLINICAL AND COMMUNITY SERVICES
Entity Type:Organization
Organization Name:FUNDERBURG CLINICAL AND COMMUNITY SERVICES
Other - Org Name:FUNDERBURG CCS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:RODERICK
Authorized Official - Last Name:FUNDERBURG
Authorized Official - Suffix:JR
Authorized Official - Credentials:LLMSW MSW
Authorized Official - Phone:248-809-9105
Mailing Address - Street 1:25438 SAINT JAMES
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1247
Mailing Address - Country:US
Mailing Address - Phone:248-809-9105
Mailing Address - Fax:248-659-1528
Practice Address - Street 1:25438 SAINT JAMES
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1247
Practice Address - Country:US
Practice Address - Phone:248-809-9105
Practice Address - Fax:248-659-1528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010861401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty