Provider Demographics
NPI:1124399282
Name:PACK, TOMMY
Entity Type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:
Last Name:PACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15526 N BRYANT RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-0201
Mailing Address - Country:US
Mailing Address - Phone:918-457-6129
Mailing Address - Fax:
Practice Address - Street 1:15526 N BRYANT RD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0201
Practice Address - Country:US
Practice Address - Phone:918-457-6129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health