1124117429 NPI number — MRS. THERESA MARIE FUNKHOUSER MS, OTR/L

Table of content: MRS. THERESA MARIE FUNKHOUSER MS, OTR/L (NPI 1124117429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124117429 NPI number — MRS. THERESA MARIE FUNKHOUSER MS, OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUNKHOUSER
Provider First Name:
THERESA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124117429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7401 MARCHE LATERAL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72118-1693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-851-2473
Provider Business Mailing Address Fax Number:
501-851-3862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7401 MARCHE LATERAL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72118-1693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-851-2473
Provider Business Practice Location Address Fax Number:
501-851-3862
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OTR1279 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5X125 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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