Provider Demographics
NPI:1285864017
Name:PARK, ABIGAIL (MS OTR/L)
Entity Type:Individual
Prefix:MS
First Name:ABIGAIL
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 SAINT MICHAELS DR
Mailing Address - Street 2:PHYSICIAN PRACTICES
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-820-5227
Mailing Address - Fax:505-913-6627
Practice Address - Street 1:2025 GALISTEO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2101
Practice Address - Country:US
Practice Address - Phone:505-995-4901
Practice Address - Fax:505-989-6483
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2475225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2475OtherNM LICENSE