Healthcare Provider Details

I. General information

NPI: 1083614671
Provider Name (Legal Business Name): JOAN ROSEN FUNK LCSW, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 POWERS FERRY RD BLDG 17 STE 100
MARIETTA GA
30067-5491
US

IV. Provider business mailing address

1640 POWERS FERRY RD BLDG 17 STE 100
MARIETTA GEORGIA
30067
CC

V. Phone/Fax

Practice location:
  • Phone: 770-426-9929
  • Fax: 770-426-8293
Mailing address:
  • Phone: 770-426-9929
  • Fax: 770-426-8293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2669
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: