Provider Demographics
NPI:1659071637
Name:PARK, SU JI
Entity Type:Individual
Prefix:
First Name:SU
Middle Name:JI
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 1:24602 SILTSTONE SQ
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-3001
Mailing Address - Country:US
Mailing Address - Phone:540-622-7415
Mailing Address - Fax:
Practice Address - Street 1:8230 LEESBURG PIKE STE 740
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-2641
Practice Address - Country:US
Practice Address - Phone:877-504-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1-23-64525103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst