Provider Demographics
NPI:1215004965
Name:PARK, KEVIN ALAN (OTR/L, CHT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ALAN
Last Name:PARK
Suffix:
Gender:M
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206B OXFORD RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-3115
Mailing Address - Country:US
Mailing Address - Phone:662-534-4445
Mailing Address - Fax:662-534-9449
Practice Address - Street 1:206B OXFORD RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3115
Practice Address - Country:US
Practice Address - Phone:662-534-4445
Practice Address - Fax:662-534-9449
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT0359225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS582681044OtherTAX ID
MS06957897Medicaid
MS582681044OtherTAX ID