Provider Demographics
NPI:1326583154
Name:PARK, SOMAKHANDEN (MI4032 AND CI5055)
Entity Type:Individual
Prefix:
First Name:SOMAKHANDEN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MI4032 AND CI5055
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 SIERRA ROSE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2060
Mailing Address - Country:US
Mailing Address - Phone:775-453-4143
Mailing Address - Fax:
Practice Address - Street 1:695 SIERRA ROSE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2060
Practice Address - Country:US
Practice Address - Phone:774-453-4143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCI5055101YP2500X
WI727-228106H00000X
NVMI4032106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional