Healthcare Provider Details

I. General information

NPI: 1285953539
Provider Name (Legal Business Name): BRYAN ANDREW FUNK MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 05/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 EASTERN AVE NE
GRAND RAPIDS MI
49501-0294
US

IV. Provider business mailing address

901 EASTERN AVE NE P.O. BOX 294
GRAND RAPIDS MI
49501-0294
US

V. Phone/Fax

Practice location:
  • Phone: 616-224-7578
  • Fax: 616-224-7581
Mailing address:
  • Phone: 616-224-7578
  • Fax: 616-224-7581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000678A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010973
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: