Healthcare Provider Details

I. General information

NPI: 1790297182
Provider Name (Legal Business Name): GEORGE S. PARK, PHD., MP., A PSYCHOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2285 BENTON RD STE 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 Number
License Number State

VIII. Authorized Official

Name: MARY S PARK
Title or Position: OFFICE MANAGER
Credential:
Phone: 318-415-8755