Provider Demographics
NPI:1619103595
Name:PARK, JOANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JOANN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 ARTHUR KILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1207
Mailing Address - Country:US
Mailing Address - Phone:718-448-3210
Mailing Address - Fax:718-984-2642
Practice Address - Street 1:65 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4325
Practice Address - Country:US
Practice Address - Phone:718-448-3210
Practice Address - Fax:718-984-2642
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073998101YA0400X
NY073998-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW11391OtherMEDICARE #