Provider Demographics
NPI:1952552853
Name:PANNECK, LAUREN KELLY (LICSW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:KELLY
Last Name:PANNECK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 415 BOX 8577
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09114-0086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:TOWER BARRACKS FAMILY ADVOCACY PROGRAM
Practice Address - Street 2:BUILDING 158
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09114
Practice Address - Country:US
Practice Address - Phone:314-590-3103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1147621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000859301OtherMEDICARE PTAN