Healthcare Provider Details

I. General information

NPI: 1376189118
Provider Name (Legal Business Name): EUNMI PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 09/17/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 J.B. WISE PLAZA
WATERTOWN NY
13601
US

IV. Provider business mailing address

PO BOX 6550
WATERTOWN NY
13601-6550
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-788-7430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP103873-01
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: