Provider Demographics
NPI:1457392912
Name:PARK, KENNETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
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 1:486 LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-2241
Mailing Address - Country:US
Mailing Address - Phone:617-797-8764
Mailing Address - Fax:
Practice Address - Street 1:486 LOWELL ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-2241
Practice Address - Country:US
Practice Address - Phone:617-398-7297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8300103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW06428OtherBCBS
Q57685Medicare UPIN