Provider Demographics
NPI:1457500761
Name:PARK, SO YEON
Entity Type:Individual
Prefix:MS
First Name:SO YEON
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CLAIRE
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:255 W 75TH ST APT 5C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-1740
Mailing Address - Country:US
Mailing Address - Phone:646-593-1515
Mailing Address - Fax:
Practice Address - Street 1:8708 JUSTICE AVE STE C7
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4590
Practice Address - Country:US
Practice Address - Phone:718-899-9810
Practice Address - Fax:718-899-9699
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NY0813931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical