Healthcare Provider Details

I. General information

NPI: 1700675139
Provider Name (Legal Business Name): SOYOUNG PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2369 2ND AVE
NEW YORK NY
10035-3108
US

IV. Provider business mailing address

4318 MAIN ST APT 7A
FLUSHING NY
11355-4754
US

V. Phone/Fax

Practice location:
  • Phone: 212-876-2300
  • Fax:
Mailing address:
  • Phone: 929-609-0132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP129461
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: