Provider Demographics
NPI:1437199031
Name:PARK, GEORGE S (PHD, MP)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:PHD, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71171-5478
Mailing Address - Country:US
Mailing Address - Phone:318-415-8755
Mailing Address - Fax:318-746-8565
Practice Address - Street 1:2285 BENTON RD BLDG 3
Practice Address - Street 2:SUITE 401
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-7933
Practice Address - Country:US
Practice Address - Phone:318-415-8755
Practice Address - Fax:318-746-8565
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMP0983103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA314936OtherMEDICARE PTAN