Provider Demographics
NPI:1053561431
Name:PARK, LORI A (MS,LCSW)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:PARK
Suffix:
Gender:F
Credentials:MS,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W BASELINE SPUR RD
Mailing Address - Street 2:
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501
Mailing Address - Country:US
Mailing Address - Phone:928-402-9297
Mailing Address - Fax:928-402-9414
Practice Address - Street 1:415 W BASELINE SPUR RD
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501
Practice Address - Country:US
Practice Address - Phone:928-402-9297
Practice Address - Fax:928-402-9414
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-125651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical