Provider Demographics
NPI:1457166035
Name:PARK, ANNETTE NARAE
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:NARAE
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:NARAE
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4133 JACKDAW ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1331
Mailing Address - Country:US
Mailing Address - Phone:818-823-1202
Mailing Address - Fax:
Practice Address - Street 1:6160 CORNERSTONE CT E STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3724
Practice Address - Country:US
Practice Address - Phone:818-823-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician