Provider Demographics
NPI:1790142230
Name:FUNDERBURK, PHILLIP JR (SUDP)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:
Last Name:FUNDERBURK
Suffix:JR
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98134-1510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4301 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2316
Practice Address - Country:US
Practice Address - Phone:877-522-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60691952101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)