Provider Demographics
NPI:1326020710
Name:PARK, RUSSELL DEAN (PHD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:DEAN
Last Name:PARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:MONTE RIO
Mailing Address - State:CA
Mailing Address - Zip Code:95462-0215
Mailing Address - Country:US
Mailing Address - Phone:209-380-3932
Mailing Address - Fax:
Practice Address - Street 1:5100 O'BYRNES FERRY RD.
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:CA
Practice Address - Zip Code:95327
Practice Address - Country:US
Practice Address - Phone:209-984-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14275103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL142750Medicare ID - Type Unspecified