Provider Demographics
NPI:1669874491
Name:PARK, ANGEL (LCAT)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 WHITE BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2625
Mailing Address - Country:US
Mailing Address - Phone:516-497-4649
Mailing Address - Fax:
Practice Address - Street 1:954 KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-2312
Practice Address - Country:US
Practice Address - Phone:516-497-4649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001638-1225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist