Provider Demographics
NPI:1003153024
Name:PARK, SUNGKUK (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUNGKUK
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6111 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4965
Mailing Address - Country:US
Mailing Address - Phone:718-205-0288
Mailing Address - Fax:
Practice Address - Street 1:4320 MURRAY ST FL 2
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1330
Practice Address - Country:US
Practice Address - Phone:718-578-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023032235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist