Basic Information
| Provider Information | |||||||||
| NPI: | 1477866176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUNK | ||||||||
| FirstName: | JANETTE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26 AVONMORE WAY | ||||||||
| Address2: | |||||||||
| City: | PENFIELD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145261624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4138844341 | ||||||||
| FaxNumber: | 5852731117 | ||||||||
| Practice Location | |||||||||
| Address1: | 1577 SOUTH AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146203914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4138844341 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2010 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 018667-1 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 12130018 | 01 | NY | CAQH | OTHER |