Provider Demographics
NPI:1457117954
Name:FUNKHOUSER, MARY NICHOLE (CDCA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:NICHOLE
Last Name:FUNKHOUSER
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 ALAMEDA DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-1203
Mailing Address - Country:US
Mailing Address - Phone:937-768-2547
Mailing Address - Fax:
Practice Address - Street 1:215 S ALLISON AVE
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-3694
Practice Address - Country:US
Practice Address - Phone:937-352-6490
Practice Address - Fax:937-888-4008
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.192961101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.192961OtherCHEMICALDEPENDENCYPROFESSIONALSBOARD