Provider Demographics
NPI:1720362304
Name:PACK, TINA LOUISE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:LOUISE
Last Name:PACK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 1ST AVE
Mailing Address - Street 2:15F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-6912
Mailing Address - Country:US
Mailing Address - Phone:917-513-5385
Mailing Address - Fax:
Practice Address - Street 1:2253 3RD AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-2206
Practice Address - Country:US
Practice Address - Phone:212-289-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083959-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker