Provider Demographics
NPI:1144747817
Name:PARK, SEUNGSUN ELLEN (AUD)
Entity Type:Individual
Prefix:
First Name:SEUNGSUN
Middle Name:ELLEN
Last Name:PARK
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 UNIVERSITY BLVD E APT 2-207
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-3665
Mailing Address - Country:US
Mailing Address - Phone:301-633-4484
Mailing Address - Fax:
Practice Address - Street 1:7955 TUCKERMAN LN # 1449
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-3243
Practice Address - Country:US
Practice Address - Phone:301-299-3717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01426231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist