Provider Demographics
NPI:1912967019
Name:PARK, DOUGLAS J (PHD)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3010
Mailing Address - Country:US
Mailing Address - Phone:313-565-5937
Mailing Address - Fax:
Practice Address - Street 1:2314 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3010
Practice Address - Country:US
Practice Address - Phone:313-565-5937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011777103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680H216560OtherBLUE CARE NETWORK
MI680H216560OtherBLUE CROSS BLUE SHIELD
MIOP14850Medicare ID - Type Unspecified