1790297182 NPI number — GEORGE S. PARK, PHD., MP., A PSYCHOLOGY CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790297182 NPI number — GEORGE S. PARK, PHD., MP., A PSYCHOLOGY CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGE S. PARK, PHD., MP., A PSYCHOLOGY CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790297182
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5478
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSSIER CITY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71171-5478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-415-8755
Provider Business Mailing Address Fax Number:
318-746-8565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2285 BENTON RD STE 401
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-7933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-415-8755
Provider Business Practice Location Address Fax Number:
318-746-8565
Provider Enumeration Date:
10/25/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
MARY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
318-415-8755

Provider Taxonomy Codes

  • Taxonomy code: 103TP0016X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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