Provider Demographics
NPI:1801112891
Name:PARK, BRANDON S (PHD)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:S
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 1:1600 9TH STREET
Mailing Address - Street 2:ROOM 205 MAILSTOP 2-3
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-654-2431
Mailing Address - Fax:916-654-3186
Practice Address - Street 1:2100 NAPA VALLEJO HWY
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6234
Practice Address - Country:US
Practice Address - Phone:707-253-5000
Practice Address - Fax:707-253-5513
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24096103TC0700X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist