Basic Information
| Provider Information | |||||||||
| NPI: | 1619093028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | WANCHOE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 SO. LAFAYETTE PK. PL. 3RD FL. | ||||||||
| Address2: | |||||||||
| City: | LA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132522100 | ||||||||
| FaxNumber: | 2133833146 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 S LA FAYETTE PARK PL | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900571607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2132522100 | ||||||||
| FaxNumber: | 2133833146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 05/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCS28421 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.