Provider Demographics
NPI:1659329274
Name:FUNDERBURK, KATHRYN JAYNE STEVENSON (LISW-CP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:JAYNE STEVENSON
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:MISS
Other - First Name:KATHRYN
Other - Middle Name:JAYNE
Other - Last Name:STEVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 N MAGNOLIA ST
Mailing Address - Street 2:SWCMHC
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4943
Mailing Address - Country:US
Mailing Address - Phone:803-775-9364
Mailing Address - Fax:803-773-6615
Practice Address - Street 1:2611 LIBERTY HILL RD
Practice Address - Street 2:SWCMHC/KERSHAW CMHC,
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-1871
Practice Address - Country:US
Practice Address - Phone:803-432-5323
Practice Address - Fax:803-713-3978
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC61521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ22818Medicare UPIN