MEDICARE: MISS SANDRA ELLEN FUNK FRA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1487707568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SANDRA ELLEN FUNK FRA

Provider Business Mailing Address
First Line	:	1334 OAK PATCH RD APT 87
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97402-3267
Country	:	US
Telephone Number	:	541-338-4836
Fax Number	:

Provider Business Practice Location Address
First Line	:	1334 OAK PATCH RD APT 87
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97402-3267
Country	:	US
Telephone Number	:	541-338-4836
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	07/08/2007

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