Provider Demographics
NPI:1790297182
Name:GEORGE S. PARK, PHD., MP., A PSYCHOLOGY CORPORATION
Entity Type:Organization
Organization Name:GEORGE S. PARK, PHD., MP., A PSYCHOLOGY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-415-8755
Mailing Address - Street 1:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71171-5478
Mailing Address - Country:US
Mailing Address - Phone:318-415-8755
Mailing Address - Fax:318-746-8565
Practice Address - Street 1:2285 BENTON RD STE 401
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-7933
Practice Address - Country:US
Practice Address - Phone:318-415-8755
Practice Address - Fax:318-746-8565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty