MEDICARE: SUZANNE I. PARK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	101643	NY
2	104100000X	Social Worker	LSW-2562	HI
3	1041C0700X	Clinical Social Worker	LCSW-4755	HI

General Provider Information

NPI Number	:	1205355807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE I. PARK LCSW

Provider Business Mailing Address
First Line	:	1109 12TH AVE STE 201
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96816-3714
Country	:	US
Telephone Number	:	831-305-0109
Fax Number	:

Provider Business Practice Location Address
First Line	:	1109 12TH AVE STE 201
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96816-3714
Country	:	US
Telephone Number	:	831-350-0109
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2017
Last Update Date	:	12/27/2022

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