Provider Demographics
NPI:1619645348
Name:FUNDUNBURKS, NICOLE (LLMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FUNDUNBURKS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 E FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-2008
Mailing Address - Country:US
Mailing Address - Phone:517-285-4431
Mailing Address - Fax:
Practice Address - Street 1:812 E JOLLY RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-6818
Practice Address - Country:US
Practice Address - Phone:517-663-2401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker