Provider Demographics
NPI:1073319240
Name:PARK, SO HYUN (OTR/L)
Entity type:Individual
Prefix:
First Name:SO HYUN
Middle Name:
Last Name:PARK
Suffix:
Gender:
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 15TH ST APT 12H
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-2027
Mailing Address - Country:US
Mailing Address - Phone:949-322-2227
Mailing Address - Fax:
Practice Address - Street 1:101 N GROVE ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-4712
Practice Address - Country:US
Practice Address - Phone:973-672-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01158300225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist