Provider Demographics
NPI:1821417668
Name:PARK, PAUL (PSYD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BROADWAY FL 12
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-3452
Mailing Address - Country:US
Mailing Address - Phone:646-504-3596
Mailing Address - Fax:
Practice Address - Street 1:1115 BROADWAY FL 12
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-3452
Practice Address - Country:US
Practice Address - Phone:646-504-3596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020500103T00000X, 103TC0700X
NJ5326103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist