Provider Demographics
NPI:1821327826
Name:PARK, ELLEN JUNG
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:JUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:E.J.
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14119 DEERBROOK LN
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-4807
Mailing Address - Country:US
Mailing Address - Phone:909-628-9904
Mailing Address - Fax:
Practice Address - Street 1:14119 DEERBROOK LN
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-4807
Practice Address - Country:US
Practice Address - Phone:909-628-9904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2736225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist