MEDICARE: JOHN PERRY FUNK LISW

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	1041C0700X	Clinical Social Worker	I-058184	NM

General Provider Information

NPI Number	:	1114110954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN PERRY FUNK LISW

Provider Business Mailing Address
First Line	:	410 N ARMIJO ST
Second Line	:	APT. 2
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2582
Country	:	US
Telephone Number	:	505-650-1111
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 N ARMIJO ST
Second Line	:	APT. 2
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-2582
Country	:	US
Telephone Number	:	505-650-1111
Fax Number	:

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

Provider Enumeration Date	:	08/24/2007
Last Update Date	:	08/24/2007

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