Provider Demographics
NPI:1699324335
Name:PARK, IRIS
Entity type:Individual
Prefix:
First Name:IRIS
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 1:433 S MANHATTAN PL UNIT 210
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-4172
Mailing Address - Country:US
Mailing Address - Phone:213-550-9857
Mailing Address - Fax:
Practice Address - Street 1:5901 GREEN VALLEY CIR STE 130
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6900
Practice Address - Country:US
Practice Address - Phone:818-616-5022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician