Healthcare Provider Details

I. General information

NPI: 1083931323
Provider Name (Legal Business Name): EUNJA PARK TALBOT PSY.D,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 HARDWOOD DR
JACKSON NJ
08527-5349
US

IV. Provider business mailing address

23 HARDWOOD DR
JACKSON NJ
08527-5349
US

V. Phone/Fax

Practice location:
  • Phone: 917-968-8209
  • Fax:
Mailing address:
  • Phone: 917-968-8209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number68019961
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5187
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number68019961
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number5187
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: