MEDICARE: RUSSELL DEAN PARK PHD

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	103TC0700X	Clinical Psychologist	PSY14275	CA

General Provider Information

NPI Number	:	1326020710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL DEAN PARK PHD

Provider Business Mailing Address
First Line	:	PO BOX 215
Second Line	:
City	:	MONTE RIO
State	:	CA
Zip	:	95462-0215
Country	:	US
Telephone Number	:	209-380-3932
Fax Number	:

Provider Business Practice Location Address
First Line	:	5100 O'BYRNES FERRY RD.
Second Line	:
City	:	JAMESTOWN
State	:	CA
Zip	:	95327
Country	:	US
Telephone Number	:	209-984-5291
Fax Number	:

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

Provider Enumeration Date	:	11/19/2005
Last Update Date	:	04/04/2013

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