Provider Demographics
NPI:1922728906
Name:PARK, SOEUN (PHD)
Entity Type:Individual
Prefix:
First Name:SOEUN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E AMERIGE AVE UNIT 241
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1920
Mailing Address - Country:US
Mailing Address - Phone:909-326-0175
Mailing Address - Fax:
Practice Address - Street 1:112 E AMERIGE AVE UNIT 241
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1920
Practice Address - Country:US
Practice Address - Phone:909-326-0175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32443103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling