Provider Demographics
NPI:1255677076
Name:PACKER, BRENT STANLEY (BS)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:STANLEY
Last Name:PACKER
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 YORK DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-3621
Mailing Address - Country:US
Mailing Address - Phone:208-201-0144
Mailing Address - Fax:
Practice Address - Street 1:1190 YORK DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-3621
Practice Address - Country:US
Practice Address - Phone:208-201-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker