Provider Demographics
NPI:1669996906
Name:FUNK, FLETCHER (PSYD)
Entity type:Individual
Prefix:
First Name:FLETCHER
Middle Name:
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 1:762 MENDOCINO AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4817
Mailing Address - Country:US
Mailing Address - Phone:310-265-3644
Mailing Address - Fax:
Practice Address - Street 1:7901 METROPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-3111
Practice Address - Country:US
Practice Address - Phone:310-265-3644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist