Provider Demographics
NPI:1588912547
Name:PARK, SONYA (PHD)
Entity type:Individual
Prefix:
First Name:SONYA
Middle Name:
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 1:1308 CAMEO LN
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-2510
Mailing Address - Country:US
Mailing Address - Phone:909-979-1338
Mailing Address - Fax:
Practice Address - Street 1:112 E AMERIGE AVE # 341
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1920
Practice Address - Country:US
Practice Address - Phone:909-979-1338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-24
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29460103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical