Provider Demographics
NPI:1811525785
Name:PARK, MICHELLE S (LMFT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:S
Last Name:PARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 164TH ST UNIT 580161
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2686
Mailing Address - Country:US
Mailing Address - Phone:718-354-6738
Mailing Address - Fax:
Practice Address - Street 1:3328 164TH ST FL 1
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-1442
Practice Address - Country:US
Practice Address - Phone:718-354-6738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001312106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist