Healthcare Provider Details

I. General information

NPI: 1538229299
Provider Name (Legal Business Name): LORI MARIE PACK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 E 1ST ST STE 406
SANTA ANA CA
92701-6358
US

IV. Provider business mailing address

1440 E 1ST ST STE 406
SANTA ANA CA
92701-6358
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax: 714-558-9488
Mailing address:
  • Phone: 714-953-4455
  • Fax: 714-558-9488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15370
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: