Provider Demographics
NPI:1831494905
Name:PACK, TRESVIL GERARD (PHD, CRC, LPC)
Entity type:Individual
Prefix:DR
First Name:TRESVIL
Middle Name:GERARD
Last Name:PACK
Suffix:
Gender:M
Credentials:PHD, CRC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11770
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-0031
Mailing Address - Country:US
Mailing Address - Phone:501-499-8699
Mailing Address - Fax:
Practice Address - Street 1:930 WINGATE ST STE D2
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4837
Practice Address - Country:US
Practice Address - Phone:501-499-8699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2012-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1101006101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional