Provider Demographics
NPI:1053132035
Name:HALEY-FUNCKE, SHANNON MARIE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:HALEY-FUNCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:HALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2288 S AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:IA
Mailing Address - Zip Code:50128-8805
Mailing Address - Country:US
Mailing Address - Phone:515-370-0369
Mailing Address - Fax:
Practice Address - Street 1:220 W 1ST ST STE B
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-1751
Practice Address - Country:US
Practice Address - Phone:515-620-3192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA124595101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health