Provider Demographics
NPI:1972847903
Name:DIANE PARK MD LLC
Entity Type:Organization
Organization Name:DIANE PARK MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-204-2477
Mailing Address - Street 1:1845 S DOBSON RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-5661
Mailing Address - Country:US
Mailing Address - Phone:480-204-2477
Mailing Address - Fax:
Practice Address - Street 1:1845 S DOBSON RD
Practice Address - Street 2:SUITE 109
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5661
Practice Address - Country:US
Practice Address - Phone:480-204-2477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32107101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1609946672OtherINDIVIDUAL NPI NUMBER