Provider Demographics
NPI:1073785747
Name:PARK, HEESUN (LCAT)
Entity Type:Individual
Prefix:
First Name:HEESUN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7405 METROPOLITAN AVE # 2F
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-2636
Mailing Address - Country:US
Mailing Address - Phone:646-825-1810
Mailing Address - Fax:
Practice Address - Street 1:7405 METROPOLITAN AVE # 2F
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-2636
Practice Address - Country:US
Practice Address - Phone:646-825-1810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001041-1221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist