Provider Demographics
NPI:1649998725
Name:PARK, AUSTEN
Entity type:Individual
Prefix:
First Name:AUSTEN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11468 WILLOW GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6015
Mailing Address - Country:US
Mailing Address - Phone:407-883-1282
Mailing Address - Fax:
Practice Address - Street 1:11468 WILLOW GARDENS DR
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-6015
Practice Address - Country:US
Practice Address - Phone:407-883-1282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health