Provider Demographics
NPI:1689388944
Name:FUNK, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:FUNK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2902 SEAPORT DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-8619
Mailing Address - Country:US
Mailing Address - Phone:208-852-6705
Mailing Address - Fax:
Practice Address - Street 1:2902 SEAPORT DR
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-8619
Practice Address - Country:US
Practice Address - Phone:208-852-6705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2070225XP0200X
WA60976943225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics