Provider Demographics
NPI:1427567726
Name:FUNKHOUSER, GERRY WADE JR (PLPC)
Entity Type:Individual
Prefix:
First Name:GERRY
Middle Name:WADE
Last Name:FUNKHOUSER
Suffix:JR
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 ASHWOOD DR APT 7
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-0102
Mailing Address - Country:US
Mailing Address - Phone:636-465-4356
Mailing Address - Fax:
Practice Address - Street 1:103 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:833-338-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017034374101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1427567726Medicaid