Basic Information
| Provider Information | |||||||||
| NPI: | 1619103595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | JOANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2535 ARTHUR KILL RD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103091207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184483210 | ||||||||
| FaxNumber: | 7189842642 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103044325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184483210 | ||||||||
| FaxNumber: | 7189842642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2009 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 073998 | NY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 073998-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.