Provider Demographics
NPI:1356472062
Name:PARK, MEGAN MICHELLE (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MICHELLE
Last Name:PARK
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N CENTRAL AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4262
Mailing Address - Country:US
Mailing Address - Phone:323-599-7668
Mailing Address - Fax:818-484-8177
Practice Address - Street 1:715 N CENTRAL AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4262
Practice Address - Country:US
Practice Address - Phone:323-599-7668
Practice Address - Fax:818-484-8177
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 44776106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9713251OtherAETNA
CAMFT447760OtherBLUE SHIELD OF CALIFORNIA