Provider Demographics
NPI:1619368552
Name:FUNK, THERESA (LBSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:LBSW
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 68327
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49516-8327
Mailing Address - Country:US
Mailing Address - Phone:616-774-0538
Mailing Address - Fax:
Practice Address - Street 1:4255 KALAMAZOO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-3638
Practice Address - Country:US
Practice Address - Phone:616-455-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802062779104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker