Healthcare Provider Details

I. General information

NPI: 1437199031
Provider Name (Legal Business Name): GEORGE S PARK PH.D., M.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2285 BENTON RD BLDG 3 SUITE 401
BOSSIER CITY LA
71111-7933
US

IV. Provider business mailing address

PO BOX 5478
BOSSIER CITY LA
71171-5478
US

V. Phone/Fax

Practice location:
  • Phone: 318-415-8755
  • Fax: 318-746-8565
Mailing address:
  • Phone: 318-415-8755
  • Fax: 318-746-8565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberMP0983
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: