Provider Demographics
NPI:1740376284
Name:PARK, CONNIE (PHD)
Entity type:Individual
Prefix:DR
First Name:CONNIE
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 1:411 PALOS VERDES DR.
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734
Mailing Address - Country:US
Mailing Address - Phone:512-659-9928
Mailing Address - Fax:
Practice Address - Street 1:410 W. LIBERTY AVE.
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664
Practice Address - Country:US
Practice Address - Phone:512-223-4829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX272101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional