Provider Demographics
NPI:1194453217
Name:PARK, ALLISON (PTA)
Entity type:Individual
Prefix:MRS
First Name:ALLISON
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9018 BRANDYWYNE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-1361
Mailing Address - Country:US
Mailing Address - Phone:270-205-0753
Mailing Address - Fax:
Practice Address - Street 1:9300 CIVIC WAY
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-6619
Practice Address - Country:US
Practice Address - Phone:502-233-3855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA04174225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty