Provider Demographics
NPI:1124016522
Name:FUNK, THOMAS J (PCC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:FUNK
Suffix:
Gender:M
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4829 MUNSON ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-3614
Mailing Address - Country:US
Mailing Address - Phone:330-244-9499
Mailing Address - Fax:330-244-9499
Practice Address - Street 1:4829 MUNSON ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3614
Practice Address - Country:US
Practice Address - Phone:330-244-9499
Practice Address - Fax:330-244-9499
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE3126101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional