Healthcare Provider Details

I. General information

NPI: 1821396433
Provider Name (Legal Business Name): WAYNE C FUNK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2011
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 KIEFER AVE
HAZLETON PA
18201-7701
US

IV. Provider business mailing address

545 KIEFER AVE
HAZLETON PA
18201-7701
US

V. Phone/Fax

Practice location:
  • Phone: 570-459-5615
  • Fax:
Mailing address:
  • Phone: 570-579-4977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW016288
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: