Provider Demographics
NPI:1083909212
Name:PARK, JOELLEN MARIE BOSCH
Entity Type:Individual
Prefix:MS
First Name:JOELLEN
Middle Name:MARIE BOSCH
Last Name:PARK
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 1:3757 EDITH PATCH DR
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-8309
Mailing Address - Country:US
Mailing Address - Phone:612-813-6138
Mailing Address - Fax:
Practice Address - Street 1:3757 EDITH PATCH DR
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-8309
Practice Address - Country:US
Practice Address - Phone:612-813-6138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical