Provider Demographics
NPI:1851437628
Name:FUNK, ROGER KEITH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:KEITH
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 1:655 LANDWEHR RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2311
Mailing Address - Country:US
Mailing Address - Phone:847-498-1699
Mailing Address - Fax:847-239-6029
Practice Address - Street 1:655 LANDWEHR RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2311
Practice Address - Country:US
Practice Address - Phone:847-498-1699
Practice Address - Fax:847-239-6029
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1672646OtherBLUE CROSS BLUE SHIELD
IL212754OtherVALUE OPTIONS
IL212754OtherVALUE OPTIONS