Provider Demographics
NPI:1881714350
Name:FUNDERBURK, PAIGE NOELLE (OTD, CLT, NDT)
Entity type:Individual
Prefix:DR
First Name:PAIGE
Middle Name:NOELLE
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:OTD, CLT, NDT
Other - Prefix:DR
Other - First Name:PAIGE
Other - Middle Name:NOELLE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD, CLT, NDT
Mailing Address - Street 1:4646 NARRAGANSETT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-2902
Mailing Address - Country:US
Mailing Address - Phone:404-455-0563
Mailing Address - Fax:
Practice Address - Street 1:4646 NARRAGANSETT AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92107-2902
Practice Address - Country:US
Practice Address - Phone:404-455-0563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004291225X00000X
CA11449225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist