Provider Demographics
NPI:1205112422
Name:FUNICELLO, ANN (LICSW)
Entity type:Individual
Prefix:MS
First Name:ANN
Middle Name:
Last Name:FUNICELLO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 WOOD COVE DR
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-6606
Mailing Address - Country:US
Mailing Address - Phone:401-822-0274
Mailing Address - Fax:
Practice Address - Street 1:54 WOOD COVE DR
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-6606
Practice Address - Country:US
Practice Address - Phone:401-822-0274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW00631041C0700X
RI0544501041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool