Provider Demographics
NPI:1568612679
Name:FUNK, DARRYL GLEN (LSATP)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:GLEN
Last Name:FUNK
Suffix:
Gender:M
Credentials:LSATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 N QUINCY ST.
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1785
Mailing Address - Country:US
Mailing Address - Phone:703-841-0703
Mailing Address - Fax:703-841-2316
Practice Address - Street 1:521 N QUINCY ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-2136
Practice Address - Country:US
Practice Address - Phone:703-841-0703
Practice Address - Fax:703-841-2316
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000027324500000X
VA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1558415968Medicaid