Provider Demographics
NPI:1235892902
Name:FUNDORA, VIRGINIA ALFONSO (PHD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:ALFONSO
Last Name:FUNDORA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 N CHURCH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2484
Mailing Address - Country:US
Mailing Address - Phone:813-448-3088
Mailing Address - Fax:
Practice Address - Street 1:1311 N CHURCH AVE STE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2484
Practice Address - Country:US
Practice Address - Phone:813-448-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11289103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist