Healthcare Provider Details

I. General information

NPI: 1134574155
Provider Name (Legal Business Name): TRACY FUNKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E CENTER ST
MANCHESTER CT
06040-5246
US

IV. Provider business mailing address

117 E CENTER ST
MANCHESTER CT
06040-5246
US

V. Phone/Fax

Practice location:
  • Phone: 860-990-9870
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2888
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: