Provider Demographics
NPI:1497325286
Name:PARK, CHI SOO
Entity Type:Individual
Prefix:
First Name:CHI SOO
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2851 S KING DR APT 1308
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2937
Mailing Address - Country:US
Mailing Address - Phone:951-217-4934
Mailing Address - Fax:
Practice Address - Street 1:70 E LAKE ST SIDE 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5913
Practice Address - Country:US
Practice Address - Phone:312-796-9507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2023-02-14
Deactivation Date:2021-06-26
Deactivation Code:
Reactivation Date:2023-02-14
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health