Provider Demographics
NPI:1710267679
Name:PARK, DANIELLE MARIE
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
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:PO BOX 1025
Mailing Address - Street 2:
Mailing Address - City:REMSENBURG
Mailing Address - State:NY
Mailing Address - Zip Code:11960-1025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4543
Practice Address - Country:US
Practice Address - Phone:631-676-5246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0079371224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant