Provider Demographics
NPI:1750729281
Name:FUNDARO, MICHELLE M (LMSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:FUNDARO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:INGELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1640 FORT STREET
Mailing Address - Street 2:SUITE D ATTN DENISE
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183
Mailing Address - Country:US
Mailing Address - Phone:734-391-3057
Mailing Address - Fax:734-391-3052
Practice Address - Street 1:2333 BIDDLE AVENUE
Practice Address - Street 2:BEHAVIORAL SERVICES
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192
Practice Address - Country:US
Practice Address - Phone:734-246-9246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010819261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical