Provider Demographics
NPI:1104380153
Name:PARK, MIJIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MIJIN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23141 MOULTON PKWY STE 213
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1204
Mailing Address - Country:US
Mailing Address - Phone:949-258-3741
Mailing Address - Fax:949-258-3742
Practice Address - Street 1:23141 MOULTON PKWY STE 213
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1204
Practice Address - Country:US
Practice Address - Phone:949-258-3741
Practice Address - Fax:949-258-3742
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30569103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty