Provider Demographics
NPI:1831648153
Name:PARK, BARBARA (PT)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 E LOCUST ST STE 101
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-3573
Mailing Address - Country:US
Mailing Address - Phone:563-332-6596
Mailing Address - Fax:563-888-1626
Practice Address - Street 1:3425 E LOCUST ST STE 101
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-3573
Practice Address - Country:US
Practice Address - Phone:563-332-6596
Practice Address - Fax:563-888-1626
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA81-3903851OtherPRIVATE INSURANCE
IA81-3903851Medicaid
IA81-3903851Medicaid
IA81-3903851Medicare PIN