Provider Demographics
NPI:1255816310
Name:PARK, DENNIS BROOKS (TCADC)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:BROOKS
Last Name:PARK
Suffix:
Gender:M
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 OLIVET CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-9755
Mailing Address - Country:US
Mailing Address - Phone:270-443-0096
Mailing Address - Fax:270-443-0080
Practice Address - Street 1:2705 OLIVET CHURCH RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9755
Practice Address - Country:US
Practice Address - Phone:270-443-0096
Practice Address - Fax:270-443-0080
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY172662101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY$$$$$$$$$Medicaid