Healthcare Provider Details

I. General information

NPI: 1659040467
Provider Name (Legal Business Name): CHRISTOPHER ALAN FUNK PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD STE 220
NORMAL IL
61761-6289
US

IV. Provider business mailing address

315 1/2 N MAIN ST
BLOOMINGTON IL
61701-3966
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3130
  • Fax:
Mailing address:
  • Phone: 770-568-3896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.010590
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: