Provider Demographics
NPI:1104313899
Name:PARK, AMANDA (LPC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CREEKSIDE CRES
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-9263
Mailing Address - Country:US
Mailing Address - Phone:757-202-5291
Mailing Address - Fax:
Practice Address - Street 1:648 INDEPENDENCE PKWY STE 400
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5207
Practice Address - Country:US
Practice Address - Phone:757-420-0530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007584101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0812000791OtherCSOTP