Provider Demographics
NPI:1033709571
Name:FUNKHOUSER, ANGELA RAE (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:RAE
Last Name:FUNKHOUSER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1073 N BRYANT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3261
Mailing Address - Country:US
Mailing Address - Phone:405-513-8186
Mailing Address - Fax:888-519-5101
Practice Address - Street 1:1073 N BRYANT AVE STE 100
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3261
Practice Address - Country:US
Practice Address - Phone:405-513-8186
Practice Address - Fax:888-519-5101
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1998224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty