Provider Demographics
NPI:1164136974
Name:PAC, KATIE ELIZABETH (EDS, NCSP)
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:ELIZABETH
Last Name:PAC
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 CORTEZ RD W STE 140
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3199
Mailing Address - Country:US
Mailing Address - Phone:941-900-4887
Mailing Address - Fax:
Practice Address - Street 1:3711 CORTEZ RD W STE 140
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3199
Practice Address - Country:US
Practice Address - Phone:941-900-4887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1387103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty