Provider Demographics
NPI:1326585415
Name:PARKS, BRIAN (PTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PARKS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CHESAPEAKE DR
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-5794
Mailing Address - Country:US
Mailing Address - Phone:302-745-0776
Mailing Address - Fax:
Practice Address - Street 1:715 E KING ST
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3505
Practice Address - Country:US
Practice Address - Phone:302-628-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ2-0000433225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant