Provider Demographics
NPI:1639701345
Name:FUNSTON, MELISSA E (LPC, CADC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:E
Last Name:FUNSTON
Suffix:
Gender:F
Credentials:LPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3899 N KILBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5896
Mailing Address - Country:US
Mailing Address - Phone:208-515-1579
Mailing Address - Fax:
Practice Address - Street 1:1603 12TH AVE RD. SUITE B
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8368
Practice Address - Country:US
Practice Address - Phone:208-442-0536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-7460101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health