Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | ||
Y | 102L00000X | Psychologist | PSY27071 | CA |
Y | 103T00000X | Psychologist | PSY27071 | CA |
NPI | 1013140268 |
---|---|
Provider Name | Mi N Park |
First Address | Los Angeles, CA 90095-6967 |
Second Address | Los Angeles, CA 90095-6967 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/09/2009 |
Last Update Date | 14/07/2015 |