Provider Demographics
NPI:1306811534
Name:PARK, AMY H (PHD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:H
Last Name:PARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-2871
Practice Address - Country:US
Practice Address - Phone:360-810-1659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003942103TC0700X
VT048-0000851103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2207559OtherCIGNA
VT540506OtherVALUE OPTIONS
VT356373OtherMHN
VT1010917Medicaid
WA8524290Medicaid
VT68315OtherBCBS
WA8873989Medicare PIN
VT356373OtherMHN