Healthcare Provider Details

I. General information

NPI: 1326020710
Provider Name (Legal Business Name): RUSSELL DEAN PARK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2005
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 O'BYRNES FERRY RD.
JAMESTOWN CA
95327
US

IV. Provider business mailing address

PO BOX 215
MONTE RIO CA
95462-0215
US

V. Phone/Fax

Practice location:
  • Phone: 209-984-5291
  • Fax:
Mailing address:
  • Phone: 209-380-3932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY14275
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: