Provider Demographics
NPI:1205913845
Name:PARK, CAROL A (LPC, RD, LD, CEDRED)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:PARK
Suffix:
Gender:F
Credentials:LPC, RD, LD, CEDRED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 N COLLINS BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3550
Mailing Address - Country:US
Mailing Address - Phone:469-324-9744
Mailing Address - Fax:972-671-2087
Practice Address - Street 1:1702 N. COLLINS BLVD. STE 207
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3550
Practice Address - Country:US
Practice Address - Phone:469-324-9744
Practice Address - Fax:972-591-2943
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66588101YM0800X, 101YP2500X
TXDT02795133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional