Provider Demographics
NPI:1962703124
Name:PARK, MEEOCK (PH D)
Entity type:Individual
Prefix:DR
First Name:MEEOCK
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 CEDAR AVE. S. #B-1
Mailing Address - Street 2:ATTN: MEEOCK PARK
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454
Mailing Address - Country:US
Mailing Address - Phone:612-272-9752
Mailing Address - Fax:612-342-1341
Practice Address - Street 1:2920 TALMAGE AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-2780
Practice Address - Country:US
Practice Address - Phone:612-272-9752
Practice Address - Fax:612-342-1341
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1838106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist