1194851808 NPI number — MS. SHANNON ELAINE PARK LCSW

Table of content: MS. SHANNON ELAINE PARK LCSW (NPI 1194851808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194851808 NPI number — MS. SHANNON ELAINE PARK LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
SHANNON
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

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:
1194851808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
145 S, HOLLY STREET
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97501-3101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-773-5664
Provider Business Mailing Address Fax Number:
541-773-5667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 S, HOLLY STREET
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97501-3101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-773-5664
Provider Business Practice Location Address Fax Number:
541-773-5667
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  L3339 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L3339 . This is a "LICENSE NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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