Provider Demographics
NPI:1508281700
Name:PARK, CARLA (LSW, LCDCIII)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LSW, LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 WOODBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1478
Mailing Address - Country:US
Mailing Address - Phone:440-669-3784
Mailing Address - Fax:
Practice Address - Street 1:823 WOODBRIDGE CT
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1478
Practice Address - Country:US
Practice Address - Phone:440-669-3784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS24589101Y00000X
OH021027101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor