Provider Demographics
NPI:1205355807
Name:PARK, SUZANNE I (LCSW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:I
Last Name:PARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 12TH AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-3714
Mailing Address - Country:US
Mailing Address - Phone:831-305-0109
Mailing Address - Fax:
Practice Address - Street 1:1109 12TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-3714
Practice Address - Country:US
Practice Address - Phone:831-350-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101643104100000X
HILSW-2562104100000X
HILCSW-47551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker