Provider Demographics
NPI:1225864671
Name:PARK, ELENA
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7225 CRESCENT PARK W APT 140
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2724
Mailing Address - Country:US
Mailing Address - Phone:562-561-8640
Mailing Address - Fax:
Practice Address - Street 1:5535 BALBOA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-1541
Practice Address - Country:US
Practice Address - Phone:818-646-7190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1184141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical