Provider Demographics
NPI:1982987723
Name:PARK, ALEXANDREA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDREA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9663 SANTA MONICA BLVD # 1058
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4303
Mailing Address - Country:US
Mailing Address - Phone:310-941-7775
Mailing Address - Fax:310-771-0977
Practice Address - Street 1:9107 WILSHIRE BLVD STE 475
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5559
Practice Address - Country:US
Practice Address - Phone:310-941-7775
Practice Address - Fax:310-771-0977
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
CA25773103G00000X, 103TC0700X, 103TA0700X, 103TF0200X, 103TR0400X, 103T00000X, 103TP2701X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth