Provider Demographics
NPI:1780466623
Name:PARK, NICHOLAS RYAN
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
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 1:510 HAIGHT AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-7205
Mailing Address - Country:US
Mailing Address - Phone:518-245-6272
Mailing Address - Fax:518-721-8343
Practice Address - Street 1:510 HAIGHT AVE STE 203
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-7205
Practice Address - Country:US
Practice Address - Phone:518-245-6272
Practice Address - Fax:518-721-8343
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117012104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty