Healthcare Provider Details

I. General information

NPI: 1679889711
Provider Name (Legal Business Name): JUDY C FUNK LSCW CLINICAL SOCIAL WORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5103 SW SURF SCOOTER ST
LEES SUMMIT MO
64082-4599
US

IV. Provider business mailing address

10042 KNOX DR
OVERLAND PARK KS
66212-5339
US

V. Phone/Fax

Practice location:
  • Phone: 816-509-4211
  • Fax:
Mailing address:
  • Phone: 913-980-4975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number200903697
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number200903697
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number200903697
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number200903697
License Number StateMO

VIII. Authorized Official

Name: JUDY C FUNK
Title or Position: OWNER
Credential: LCSW
Phone: 913-980-4975