Healthcare Provider Details

I. General information

NPI: 1518020338
Provider Name (Legal Business Name): ROCHELLE RENEE PARK MA, LPC, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28000 ROAD T
DOLORES CO
81323-9203
US

IV. Provider business mailing address

91 LOGGING TRAIL RD
DURANGO CO
81303-3625
US

V. Phone/Fax

Practice location:
  • Phone: 970-882-1253
  • Fax: 970-882-1500
Mailing address:
  • Phone: 970-259-9284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC4222
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0116501
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: