Healthcare Provider Details

I. General information

NPI: 1861893638
Provider Name (Legal Business Name): MISTY FUNK MSSA, LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1744 PAYNE AVE FRONTLINE SERVICE
CLEVELAND OH
44114-2910
US

IV. Provider business mailing address

1744 PAYNE AVE APT 103
CLEVELAND OH
44114-2910
US

V. Phone/Fax

Practice location:
  • Phone: 216-623-6555
  • Fax:
Mailing address:
  • Phone: 216-623-6555
  • Fax: 216-623-6539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1450321-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: