Provider Demographics
NPI:1346360658
Name:FUNDERBURK, KIM EVANGELINE (MSW)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:EVANGELINE
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2644
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0333
Mailing Address - Country:US
Mailing Address - Phone:509-240-2644
Mailing Address - Fax:509-524-0260
Practice Address - Street 1:401 W MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2837
Practice Address - Country:US
Practice Address - Phone:509-240-2644
Practice Address - Fax:509-524-0260
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW600206751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8926907Medicare PIN