Provider Demographics
NPI:1255699880
Name:FUNK, KRISTIN (MA, LCSW)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:MA, LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KRISTIN
Other - Last Name:FUNK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, LCSW
Mailing Address - Street 1:261 E 16TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4105
Mailing Address - Country:US
Mailing Address - Phone:541-579-1031
Mailing Address - Fax:
Practice Address - Street 1:261 E 16TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4105
Practice Address - Country:US
Practice Address - Phone:541-579-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL43501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical