Provider Demographics
NPI:1205034691
Name:PARK, LOVINGLY QUITANIA (PHD)
Entity Type:Individual
Prefix:
First Name:LOVINGLY
Middle Name:QUITANIA
Last Name:PARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LOVINGLY
Other - Middle Name:CLARIS
Other - Last Name:QUITANIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1901 BROADVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1201
Mailing Address - Country:US
Mailing Address - Phone:818-800-8697
Mailing Address - Fax:
Practice Address - Street 1:1901 BROADVIEW DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1201
Practice Address - Country:US
Practice Address - Phone:818-800-8697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 25525103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist