Provider Demographics
NPI:1578632816
Name:FUNDERBURK, MARLYSA (PT)
Entity Type:Individual
Prefix:
First Name:MARLYSA
Middle Name:
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 NORTHEAST EXPY NE
Mailing Address - Street 2:BUILDING 8 SUITE E
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-3932
Mailing Address - Country:US
Mailing Address - Phone:770-631-8277
Mailing Address - Fax:770-631-9403
Practice Address - Street 1:3300 NORTHEAST EXPY NE
Practice Address - Street 2:BUILDING 8 SUITE E
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-3932
Practice Address - Country:US
Practice Address - Phone:770-500-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007465225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT007465OtherSTATE LISC NUMBER