Provider Demographics
NPI:1659040467
Name:FUNK, CHRISTOPHER ALAN (PSYD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ALAN
Last Name:FUNK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 1/2 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3966
Mailing Address - Country:US
Mailing Address - Phone:770-568-3896
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT JESSE RD STE 220
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6289
Practice Address - Country:US
Practice Address - Phone:309-664-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010590103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical