| Doctor Name: | MAYO R FUNDERBURG |
| NPI Number: | 1053612192 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LADCA |
| License Number: | 2282 |
| Business Practice Address: | 20 Vesper Ln Unit L1 Nantucket, MA - 025544394 |
| Business Phone Number: | 5082282689 |
| Business Fax Number: | 5082283613 |
| Mailing Address: | 20 Vesper Ln Unit L1, NANTUCKET |
| State: | MA |
| Postal Code: | 025544394 |
| Phone Number: | 5082282689 |
| Fax Number: | 5082283613 |
| NPI Enumeration Date: | 11/05/2010 |
| NPI Last Update Date: | 11/05/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 2282 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |