Provider Demographics
NPI:1083614671
Name:FUNK, JOAN ROSEN (LCSW, PHD)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:ROSEN
Last Name:FUNK
Suffix:
Gender:F
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 POWERS FERRY RD
Mailing Address - Street 2:BLDG 17 STE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GEORGIA
Mailing Address - Zip Code:30067
Mailing Address - Country:CC
Mailing Address - Phone:770-426-9929
Mailing Address - Fax:770-426-8293
Practice Address - Street 1:1640 POWERS FERRY RD
Practice Address - Street 2:BLDG 17 STE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-426-9929
Practice Address - Fax:770-426-8293
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2669101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
80BBFCXMedicare PIN