Provider Demographics
NPI:1275237521
Name:PARK, HEEJUNG (SUDPT)
Entity Type:Individual
Prefix:
First Name:HEEJUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 BOBCAT LN NW
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5703
Mailing Address - Country:US
Mailing Address - Phone:253-652-9975
Mailing Address - Fax:
Practice Address - Street 1:4629 168TH ST SW STE E
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-8640
Practice Address - Country:US
Practice Address - Phone:253-652-9975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61420788101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
101Y99995LOtherAGENCY AFFILIATED