Provider Demographics
NPI:1629350905
Name:PARK, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
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 1:1855 W KATELLA AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-3451
Mailing Address - Country:US
Mailing Address - Phone:714-399-3480
Mailing Address - Fax:
Practice Address - Street 1:1855 W KATELLA AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-3451
Practice Address - Country:US
Practice Address - Phone:714-399-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker