MEDICARE: MRS. JOAN ROSEN FUNK LCSW, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2669	GA

General Provider Information

NPI Number	:	1083614671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOAN ROSEN FUNK LCSW, PHD

Provider Business Mailing Address
First Line	:	1640 POWERS FERRY RD
Second Line	:	BLDG 17 STE 100
City	:	MARIETTA
State	:	GEORGIA
Zip	:	30067
Country	:	CC
Telephone Number	:	770-426-9929
Fax Number	:	770-426-8293

Provider Business Practice Location Address
First Line	:	1640 POWERS FERRY RD
Second Line	:	BLDG 17 STE 100
City	:	MARIETTA
State	:	GA
Zip	:	30067-5491
Country	:	US
Telephone Number	:	770-426-9929
Fax Number	:	770-426-8293

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/26/2011

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