Provider Demographics
NPI:1356608590
Name:FUNDERBURK, KATHLEEN DIXON (LPC, LMFT, LAC, BAS,)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DIXON
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:LPC, LMFT, LAC, BAS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 HACKER ST
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-4564
Mailing Address - Country:US
Mailing Address - Phone:337-364-4644
Mailing Address - Fax:
Practice Address - Street 1:432 HACKER ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4564
Practice Address - Country:US
Practice Address - Phone:337-303-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA977101YA0400X
NC88572101YM0800X
LA2680101YP2500X
LA704106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA704OtherLICENSED MARRIAGE AND FAMILY THERAPIST
NC88572OtherNATIONALLY CERTIFIED COUNSELOR
LA977OtherLICENSED ADDICTION COUNSELOR
LAS2680OtherBOARD APPROVED SUPERVISOR FOR COUNSELOR INTERNS
LA2680OtherLICENSED PROFESSIONAL COUNSELOR