Provider Demographics
NPI:1215539333
Name:PACK, TEISHA NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:TEISHA
Middle Name:NICOLE
Last Name:PACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 BENT PINE DR APT 420A
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-4934
Mailing Address - Country:US
Mailing Address - Phone:407-425-6204
Mailing Address - Fax:407-542-6204
Practice Address - Street 1:6225 BENT PINE DR APT 420A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-4934
Practice Address - Country:US
Practice Address - Phone:407-425-6204
Practice Address - Fax:407-542-6204
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW174891041C0700X
NCC0170491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical