MEDICARE: JANICE PARK

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	101YM0800X	Mental Health Counselor	89878	TX

General Provider Information

NPI Number	:	1720702418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANICE PARK

Provider Business Mailing Address
First Line	:	4348 PEREGRINE WAY
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75010-4686
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8400 STACY RD STE 100
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75070-2144
Country	:	US
Telephone Number	:	469-892-8842
Fax Number	:

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

Provider Enumeration Date	:	09/27/2022
Last Update Date	:	09/27/2022

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Directions to “ JANICE PARK ” Practice Location

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