Provider Demographics
NPI:1710674635
Name:FUNG-A-FAT, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FUNG-A-FAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2291 SW 164TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4480
Mailing Address - Country:US
Mailing Address - Phone:754-265-8790
Mailing Address - Fax:
Practice Address - Street 1:100 S BROAD ST STE 1920
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19110-1064
Practice Address - Country:US
Practice Address - Phone:267-838-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health