Provider Demographics
NPI:1619509155
Name:PARK, EUNG GYEONG
Entity Type:Individual
Prefix:
First Name:EUNG
Middle Name:GYEONG
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EUNICE
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1333 S MAYFLOWER AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-5239
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:
Practice Address - Street 1:3111 N TUSTIN ST STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1751
Practice Address - Country:US
Practice Address - Phone:818-241-6780
Practice Address - Fax:800-819-7806
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23667225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist