MEDICARE: DR. BONNIE CHANGHEE PARK PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	015206-1	NY

General Provider Information

NPI Number	:	1508825274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONNIE CHANGHEE PARK PH.D.

Provider Business Mailing Address
First Line	:	1597 RIDGE ROAD WEST
Second Line	:	SUITE 301
City	:	ROCHESTER
State	:	NY
Zip	:	14615
Country	:	US
Telephone Number	:	585-865-0230
Fax Number	:	585-865-0234

Provider Business Practice Location Address
First Line	:	1597 RIDGE ROAD WEST
Second Line	:	SUITE 301
City	:	ROCHESTER
State	:	NY
Zip	:	14615
Country	:	US
Telephone Number	:	585-865-0230
Fax Number	:	585-865-0234

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	07/08/2007

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