Provider Demographics
NPI:1235253634
Name:PARK, SUSAN S (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:S
Last Name:PARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4650 W SUNSET BLVD
Mailing Address - Street 2:MS140
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6062
Mailing Address - Country:US
Mailing Address - Phone:323-361-8866
Mailing Address - Fax:323-361-3843
Practice Address - Street 1:210 S DE LACEY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2048
Practice Address - Country:US
Practice Address - Phone:626-395-7100
Practice Address - Fax:818-897-1766
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21718103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical