Provider Demographics
NPI:1114195492
Name:PARKS, JAMES DARRYL (FAODP)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:DARRYL
Last Name:PARKS
Suffix:
Gender:M
Credentials:FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9605 GRAND RIVER AVE.
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204
Mailing Address - Country:US
Mailing Address - Phone:313-834-5930
Mailing Address - Fax:313-834-4541
Practice Address - Street 1:9605 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2139
Practice Address - Country:US
Practice Address - Phone:313-834-5930
Practice Address - Fax:313-834-4541
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI820198101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI820198Medicaid