Basic Information
| Provider Information | |||||||||
| NPI: | 1992961197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | STACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 W OLYMPIC BLVD FL 3A-100 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900151019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132369394 | ||||||||
| FaxNumber: | 2132369662 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 W OLYMPIC BLVD FL 3A-100 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900151019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2135531884 | ||||||||
| FaxNumber: | 2132369662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 06/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS23522 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.