Provider Demographics
NPI:1407179971
Name:PARK, KEY H (LCAT)
Entity Type:Individual
Prefix:MISS
First Name:KEY
Middle Name:H
Last Name:PARK
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2833 201ST ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-2320
Mailing Address - Country:US
Mailing Address - Phone:917-331-2029
Mailing Address - Fax:
Practice Address - Street 1:421 27TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-4510
Practice Address - Country:US
Practice Address - Phone:718-777-6377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05000798101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health