MEDICARE: FUNCTIONAL RD, LLC

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
2	133V00000X	Registered Dietitian	DT83404	TX

General Provider Information

NPI Number	:	1932627312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONAL RD, LLC

Provider Business Mailing Address
First Line	:	14439 NW MILITARY HWY STE 108
Second Line	:
City	:	SHAVANO PARK
State	:	TX
Zip	:	78231-1648
Country	:	US
Telephone Number	:	210-920-0669
Fax Number	:	210-920-6645

Provider Business Practice Location Address
First Line	:	11107 WURZBACH RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-2500
Country	:	US
Telephone Number	:	210-920-0669
Fax Number	:	210-920-6645

Authorized Official
Title or Position	:	REGISTERED DIETITIAN
Name	:	AIMEE ELIZABETH SENIOR
Credential	:	RD, LD
Telephone Number	:	210-920-0669

Provider Enumeration Date	:	09/06/2017
Last Update Date	:	01/20/2026

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