Provider Demographics
NPI:1508333451
Name:PACUK, KATIE L
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:L
Last Name:PACUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1378 ACQUTUCK RD
Mailing Address - Street 2:
Mailing Address - City:RAVENA
Mailing Address - State:NY
Mailing Address - Zip Code:12143-3208
Mailing Address - Country:US
Mailing Address - Phone:518-549-6500
Mailing Address - Fax:
Practice Address - Street 1:75 NEW SCOTLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3409
Practice Address - Country:US
Practice Address - Phone:518-429-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090871104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker