Provider Demographics
NPI:1770223869
Name:PARK, ELIZABETH SUNG
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SUNG
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 1:2515 FAIRWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1407
Mailing Address - Country:US
Mailing Address - Phone:213-800-2881
Mailing Address - Fax:
Practice Address - Street 1:1230 ROSECRANS AVE STE 300
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-2494
Practice Address - Country:US
Practice Address - Phone:310-561-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122316106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist