Provider Demographics
NPI:1053659482
Name:FUNK, BRENT (PSYD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:FUNK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL
Mailing Address - Street 2:1E
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-6651
Mailing Address - Fax:
Practice Address - Street 1:1 FORD PL
Practice Address - Street 2:1E
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3450
Practice Address - Country:US
Practice Address - Phone:313-874-6651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014872103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist