Provider Demographics
NPI:1780195305
Name:PACK, LEANNDRA (LCSW)
Entity type:Individual
Prefix:
First Name:LEANNDRA
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LEANNDRA
Other - Middle Name:
Other - Last Name:FAIRCHILD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2342 N CORNWALL AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6400
Mailing Address - Country:US
Mailing Address - Phone:408-883-5455
Mailing Address - Fax:
Practice Address - Street 1:2342 N CORNWALL AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-6400
Practice Address - Country:US
Practice Address - Phone:408-883-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR10154-C1041C0700X
AR10154M104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator