Provider Demographics
NPI:1013237353
Name:PARK, YEDDI (MSW)
Entity Type:Individual
Prefix:MS
First Name:YEDDI
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 GRAND AVE
Mailing Address - Street 2:7A
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-2256
Mailing Address - Country:US
Mailing Address - Phone:201-920-5015
Mailing Address - Fax:
Practice Address - Street 1:372 GRAND AVE
Practice Address - Street 2:7A
Practice Address - City:LEONIA
Practice Address - State:NJ
Practice Address - Zip Code:07605-2256
Practice Address - Country:US
Practice Address - Phone:201-920-5015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2010-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY076492-11041S0200X
NJ44SL05242700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker