Provider Demographics
NPI:1619429669
Name:PARK, ISSA (LMHC)
Entity Type:Individual
Prefix:
First Name:ISSA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 JAY ELL DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-1838
Mailing Address - Country:US
Mailing Address - Phone:254-554-1810
Mailing Address - Fax:
Practice Address - Street 1:1900 JAY ELL DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-1838
Practice Address - Country:US
Practice Address - Phone:254-554-1810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX87758101YP2500X
WALH60687373101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional