Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 9694 | CA |
NPI | 1003204991 |
---|---|
Provider Name | Judie Park |
First Address | Van Nuys, CA 91405-1631 |
Second Address | Van Nuys, CA 91405-1631 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/12/2014 |
Last Update Date | 31/12/2014 |