# EDMUND PARK

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1881146462
- **Gender:** Man
- **Credential:** M.DIV

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YM0800X | Mental Health Counselor | MC 60176362 | WA | Yes |

## Other

- **Enumeration date:** 10/28/2016
- **Last updated:** 10/28/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 777232A01NYJ | PREMERA BLUE CROSS | WA |