Provider Demographics
NPI:1619220423
Name:PARK, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
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 1:10 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2314
Mailing Address - Country:US
Mailing Address - Phone:716-488-2322
Mailing Address - Fax:716-488-2574
Practice Address - Street 1:15 S MAIN ST
Practice Address - Street 2:SUITE 220
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6626
Practice Address - Country:US
Practice Address - Phone:716-488-2322
Practice Address - Fax:716-488-2574
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008030225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant