Provider Demographics
NPI:1750469185
Name:PACK, LOTHELL (MA, EDS)
Entity Type:Individual
Prefix:MRS
First Name:LOTHELL
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:MA, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-9605
Mailing Address - Country:US
Mailing Address - Phone:304-792-2087
Mailing Address - Fax:304-752-7471
Practice Address - Street 1:66 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-9605
Practice Address - Country:US
Practice Address - Phone:304-792-2087
Practice Address - Fax:304-752-7471
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21037103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0166298000Medicaid