Provider Demographics
NPI:1588151153
Name:PARK, CALI D
Entity type:Individual
Prefix:
First Name:CALI
Middle Name:D
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:PO BOX 1101
Mailing Address - Street 2:
Mailing Address - City:NORLINA
Mailing Address - State:NC
Mailing Address - Zip Code:27563-1101
Mailing Address - Country:US
Mailing Address - Phone:252-425-5341
Mailing Address - Fax:
Practice Address - Street 1:5809 DEPARTURE DR STE 106
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-1936
Practice Address - Country:US
Practice Address - Phone:919-872-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health