Healthcare Provider Details

I. General information

NPI: 1730847286
Provider Name (Legal Business Name): PARK FAMILY THERAPY & ASSOCIATES, A CALIFORNIA MFT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30011 IVY GLENN DR. STE 105
LAGUNA NIGUEL CA
92677
US

IV. Provider business mailing address

5319 UNIVERSITY DR STE 457
IRVINE CA
92612-2965
US

V. Phone/Fax

Practice location:
  • Phone: 949-385-2732
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER PARK
Title or Position: SUPERVISOR
Credential:
Phone: 949-891-5336