Provider Demographics
NPI:1245611615
Name:FUNK, SANDRA (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14549 QUAIL TRAIL CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-7080
Mailing Address - Country:US
Mailing Address - Phone:407-373-9247
Mailing Address - Fax:
Practice Address - Street 1:9848 TABOR ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-3964
Practice Address - Country:US
Practice Address - Phone:407-373-9247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13214235Z00000X
CASP24281235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist