Individual
GERRY WADE FUNKHOUSER JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PLPC
Contact information
Practice address
103 W 10TH ST, ROLLA, MO 65401
(833) 338-4673
Mailing address
1700 ASHWOOD DR APT 7, ROLLA, MO 65401-0102
(636) 465-4356
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
2017034374
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1427567726
—
MO
Enumeration date
09/29/2017
Last updated
03/06/2019
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