Provider Demographics
NPI:1326355041
Name:PARK, BOHYUN (MA)
Entity Type:Individual
Prefix:
First Name:BOHYUN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 E JEFFERSON ST
Mailing Address - Street 2:ATTN: ANNE LAWSON
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-3880
Mailing Address - Country:US
Mailing Address - Phone:574-267-7169
Mailing Address - Fax:574-269-4189
Practice Address - Street 1:850 N HARRISON ST
Practice Address - Street 2:ATTN: ANNE LAWSON
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3163
Practice Address - Country:US
Practice Address - Phone:574-267-7169
Practice Address - Fax:574-268-2377
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34007706A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical