Provider Demographics
NPI:1275814550
Name:FUNDENBERGER, REBECCA KAYE
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:KAYE
Last Name:FUNDENBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 W MARCH LN STE 125
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8224
Mailing Address - Country:US
Mailing Address - Phone:925-437-1055
Mailing Address - Fax:
Practice Address - Street 1:2495 W MARCH LN STE 125
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8224
Practice Address - Country:US
Practice Address - Phone:209-465-1080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93610106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist