Provider Demographics
NPI:1295581189
Name:PARK, JAMES BYUNG (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:BYUNG
Last Name:PARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 STONEBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-9501
Mailing Address - Country:US
Mailing Address - Phone:310-295-8174
Mailing Address - Fax:
Practice Address - Street 1:18000 E PERIMETER ROAD
Practice Address - Street 2:
Practice Address - City:CAMP ROBERTS
Practice Address - State:CA
Practice Address - Zip Code:93451
Practice Address - Country:US
Practice Address - Phone:805-227-7833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810008050103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist