Provider Demographics
NPI:1275001463
Name:VANESSA FUNK, MA, LPC, PLLC
Entity Type:Organization
Organization Name:VANESSA FUNK, MA, LPC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:V
Authorized Official - Last Name:FUNK
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:405-719-6802
Mailing Address - Street 1:2529 S KELLY AVE STE C
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2976
Mailing Address - Country:US
Mailing Address - Phone:405-245-8257
Mailing Address - Fax:
Practice Address - Street 1:2529 S KELLY AVE STE C
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-2976
Practice Address - Country:US
Practice Address - Phone:405-245-8257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1841519972Medicaid