Provider Demographics
NPI:1174861173
Name:PARK, JUNNE Y (BCABA)
Entity Type:Individual
Prefix:
First Name:JUNNE
Middle Name:Y
Last Name:PARK
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 NE FAIRGROUNDS ROAD
Mailing Address - Street 2:#15
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311
Mailing Address - Country:US
Mailing Address - Phone:808-391-1295
Mailing Address - Fax:
Practice Address - Street 1:155 NE FAIRGROUNDS RD
Practice Address - Street 2:#15
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-8851
Practice Address - Country:US
Practice Address - Phone:808-391-1295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-11-4287103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-11-4287OtherBEHAVIOR ANALYST CERTIFICATION BOARD