Basic Information
| Provider Information | |||||||||
| NPI: | 1124556956 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29260 FRANKLIN RD APT 304 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480341157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133463717 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20600 EUREKA RD STE 819 | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481805377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342858282 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | GRETA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7344172487 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.