Provider Demographics
NPI:1821214982
Name:PACKER, CYNTHIA (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:
Last Name:PACKER
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3836 18TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-2823
Mailing Address - Country:US
Mailing Address - Phone:612-722-8154
Mailing Address - Fax:
Practice Address - Street 1:1711 COUNTY ROAD B W
Practice Address - Street 2:100F
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4057
Practice Address - Country:US
Practice Address - Phone:612-306-1578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN043831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical