| Doctor Name: | SAMUEL PARK |
| NPI Number: | 1205222510 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 0810005121 |
| Business Practice Address: | 3200 St Martins Trl Apt 1109 Henrico, VA - 232944919 |
| Business Phone Number: | 8046471182 |
| Business Fax Number: | |
| Mailing Address: | 3200 St Martins Trl Apt 1109, HENRICO |
| State: | VA |
| Postal Code: | 232944919 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 04/13/2015 |
| NPI Last Update Date: | 04/13/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 0810005121 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | VA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |