Basic Information
| Provider Information | |||||||||
| NPI: | 1750418646 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUNK | ||||||||
| FirstName: | LEEANN | ||||||||
| MiddleName: | JEANETTE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2161 NW MILITARY HWY | ||||||||
| Address2: | CMSE SUITE 308 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782131878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103413336 | ||||||||
| FaxNumber: | 2103413455 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 W LOSEY ST | ||||||||
| Address2: | FAMILY ADVOCACY PROGRAM BUILDING 1533 | ||||||||
| City: | SCOTT AIR FORCE BASE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622255250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182567203 | ||||||||
| FaxNumber: | 6182567246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2001004059 | MO | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 149.009427 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.