Provider Demographics
NPI:1962040139
Name:PARK, SOYUL
Entity Type:Individual
Prefix:
First Name:SOYUL
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 1:14444 41ST AVE APT J
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-1545
Mailing Address - Country:US
Mailing Address - Phone:347-720-3640
Mailing Address - Fax:
Practice Address - Street 1:14444 41ST AVE APT J
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1545
Practice Address - Country:US
Practice Address - Phone:347-720-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022528225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist