Provider Demographics
NPI:1144282302
Name:PARKS, ROGER L (PSYD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:PARKS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1251
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-1251
Mailing Address - Country:US
Mailing Address - Phone:616-942-8060
Mailing Address - Fax:616-942-6690
Practice Address - Street 1:15127 S 73RD AVE
Practice Address - Street 2:SUITE G
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462
Practice Address - Country:US
Practice Address - Phone:616-942-8060
Practice Address - Fax:616-942-6690
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical