Provider Demographics
NPI:1437483518
Name:PACK, NATHANIEL M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:M
Last Name:PACK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
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Mailing Address - Street 1:171 MAIN ST
Mailing Address - Street 2:#565
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-2912
Mailing Address - Country:US
Mailing Address - Phone:415-785-8599
Mailing Address - Fax:650-600-8682
Practice Address - Street 1:117 S CALIFORNIA AVE
Practice Address - Street 2:STE. D201
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-5103
Practice Address - Country:US
Practice Address - Phone:415-847-6960
Practice Address - Fax:650-600-8682
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-23
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY22991103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADA499AMedicare UPIN