Provider Demographics
NPI:1043754864
Name:PARK RICHARDS, SHAY EILEEN
Entity Type:Individual
Prefix:
First Name:SHAY
Middle Name:EILEEN
Last Name:PARK RICHARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8791 NUMBER FOUR RD
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-3258
Mailing Address - Country:US
Mailing Address - Phone:315-376-5958
Mailing Address - Fax:315-376-5953
Practice Address - Street 1:7714 NUMBER THREE RD
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-3521
Practice Address - Country:US
Practice Address - Phone:315-376-5958
Practice Address - Fax:315-376-5953
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099592104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker