Provider Demographics
NPI:1053480129
Name:PARK, SCOTT DAVID (LICSW)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DAVID
Last Name:PARK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609
Mailing Address - Country:US
Mailing Address - Phone:508-752-5191
Mailing Address - Fax:508-792-1514
Practice Address - Street 1:52 CEDAR ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609
Practice Address - Country:US
Practice Address - Phone:508-752-5191
Practice Address - Fax:508-792-1514
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1108031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23966Medicare ID - Type Unspecified