Provider Demographics
NPI:1891039541
Name:PARK, ALYSSA L (LCPC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:L
Last Name:PARK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:L
Other - Last Name:FAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6324
Mailing Address - Country:US
Mailing Address - Phone:217-525-1064
Mailing Address - Fax:217-525-1651
Practice Address - Street 1:5220 S 6TH STREET RD
Practice Address - Street 2:SUITE 2400
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5735
Practice Address - Country:US
Practice Address - Phone:217-757-7700
Practice Address - Fax:217-757-7799
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008205101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional