Provider Demographics
NPI:1912558909
Name:PARK, YVONNE
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:
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 1:5247 E 600 S-57
Mailing Address - Street 2:
Mailing Address - City:CHURUBUSCO
Mailing Address - State:IN
Mailing Address - Zip Code:46723-9111
Mailing Address - Country:US
Mailing Address - Phone:260-609-0429
Mailing Address - Fax:
Practice Address - Street 1:5247 E 600 S-57
Practice Address - Street 2:
Practice Address - City:CHURUBUSCO
Practice Address - State:IN
Practice Address - Zip Code:46723-9111
Practice Address - Country:US
Practice Address - Phone:260-609-0429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN222Q00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist