Basic Information
| Provider Information | |||||||||
| NPI: | 1003153024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | SUNGKUK | ||||||||
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| Credential: | M.S., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6111 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182050288 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4320 MURRAY ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113551330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185788708 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2013 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 023032 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.