Healthcare Provider Details

I. General information

NPI: 1629710694
Provider Name (Legal Business Name): SO YEON PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date: 07/09/2026
Reactivation Date: 07/29/2026

III. Provider practice location address

3723 W 12600 S
RIVERTON UT
84065-7295
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-285-4543
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number14284686-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: