Provider Demographics
NPI:1871235531
Name:PARK, COURTNEY JOEL (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:JOEL
Last Name:PARK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 HALL ST STE H
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-3442
Mailing Address - Country:US
Mailing Address - Phone:603-228-9160
Mailing Address - Fax:
Practice Address - Street 1:124 HALL ST STE H
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3442
Practice Address - Country:US
Practice Address - Phone:603-228-9160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2219235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3137186Medicaid