Provider Demographics
NPI:1659801173
Name:PARK, STACEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6314 19TH ST W STE 14
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6314 19TH ST W STE 14
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6223
Practice Address - Country:US
Practice Address - Phone:253-239-2310
Practice Address - Fax:253-239-2311
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2022-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60880262103TC2200X
CA28774103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling