Provider Demographics
NPI:1407918253
Name:FUNK, MICHAEL J (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:FUNK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1074
Mailing Address - Street 2:
Mailing Address - City:TAVERNIER
Mailing Address - State:FL
Mailing Address - Zip Code:33070-1074
Mailing Address - Country:US
Mailing Address - Phone:305-393-3544
Mailing Address - Fax:
Practice Address - Street 1:171 HOOD AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:TAVERNIER
Practice Address - State:FL
Practice Address - Zip Code:33070-2645
Practice Address - Country:US
Practice Address - Phone:305-853-3284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2009-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3550103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75625ZMedicare PIN