Provider Demographics
NPI:1285963694
Name:PARK, JUDITH JUSTIN
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:JUSTIN
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 1:1870 CORDELL CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-0914
Mailing Address - Country:US
Mailing Address - Phone:619-448-9700
Mailing Address - Fax:619-448-9711
Practice Address - Street 1:1870 CORDELL CT
Practice Address - Street 2:SUITE 101
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-0914
Practice Address - Country:US
Practice Address - Phone:619-448-9700
Practice Address - Fax:619-448-9711
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 57669101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health