Provider Demographics
NPI:1932658283
Name:FUNK, MIRA
Entity Type:Individual
Prefix:
First Name:MIRA
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 1:4842 SW ASTER ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-1364
Mailing Address - Country:US
Mailing Address - Phone:617-852-8749
Mailing Address - Fax:541-257-5485
Practice Address - Street 1:4842 SW ASTER ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1364
Practice Address - Country:US
Practice Address - Phone:541-224-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical