Healthcare Provider Details

I. General information

NPI: 1235253634
Provider Name (Legal Business Name): SUSAN S. PARK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S DE LACEY AVE SUITE 100
PASADENA CA
91105-2048
US

IV. Provider business mailing address

4650 W SUNSET BLVD MS140
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax: 818-897-1766
Mailing address:
  • Phone: 323-361-8866
  • Fax: 323-361-3843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21718
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: