Provider Demographics
NPI:1164424883
Name:PARK, PATRICIA S (SLP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:S
Last Name:PARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 MAIN ST
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3907
Mailing Address - Country:US
Mailing Address - Phone:703-279-4394
Mailing Address - Fax:703-279-4214
Practice Address - Street 1:3750 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1742
Practice Address - Country:US
Practice Address - Phone:703-391-1026
Practice Address - Fax:703-391-1027
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2010-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202-003368235Z00000X
MD03053235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist