Provider Demographics
NPI:1477979490
Name:FUNDERBURK, LUCILLE PATALANO (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LUCILLE
Middle Name:PATALANO
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-4818
Mailing Address - Country:US
Mailing Address - Phone:407-312-4585
Mailing Address - Fax:
Practice Address - Street 1:445 W AMELIA ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-1129
Practice Address - Country:US
Practice Address - Phone:407-858-3140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL000SA11971235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist