Provider Demographics
NPI:1477071603
Name:PARK, CAROL S (LSW)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:S
Last Name:PARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1109
Mailing Address - Country:US
Mailing Address - Phone:312-560-6129
Mailing Address - Fax:
Practice Address - Street 1:1841 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7603
Practice Address - Country:US
Practice Address - Phone:212-333-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06187800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker