Provider Demographics
NPI:1619408846
Name:FUNK, BETHANY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 SIGGELKOW RD APT 208
Mailing Address - Street 2:
Mailing Address - City:MC FARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558-8777
Mailing Address - Country:US
Mailing Address - Phone:608-770-4160
Mailing Address - Fax:
Practice Address - Street 1:4606 SIGGELKOW RD APT 208
Practice Address - Street 2:
Practice Address - City:MC FARLAND
Practice Address - State:WI
Practice Address - Zip Code:53558-8777
Practice Address - Country:US
Practice Address - Phone:608-770-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program