Provider Demographics
NPI:1932284957
Name:PARK, KATHY (SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ABBEY RD
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-4215
Mailing Address - Country:US
Mailing Address - Phone:817-685-7808
Mailing Address - Fax:254-965-3618
Practice Address - Street 1:1052 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-4558
Practice Address - Country:US
Practice Address - Phone:254-965-3611
Practice Address - Fax:254-965-3618
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19126235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist