MEDICARE: TEISHA NICOLE PACK LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW17489	FL
2	1041C0700X	Clinical Social Worker	C017049	NC

General Provider Information

NPI Number	:	1215539333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEISHA NICOLE PACK LCSW

Provider Business Mailing Address
First Line	:	6225 BENT PINE DR APT 420A
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-4934
Country	:	US
Telephone Number	:	407-425-6204
Fax Number	:	407-542-6204

Provider Business Practice Location Address
First Line	:	6225 BENT PINE DR APT 420A
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-4934
Country	:	US
Telephone Number	:	407-425-6204
Fax Number	:	407-542-6204

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2020
Last Update Date	:	01/30/2025

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Directions to “ TEISHA NICOLE PACK LCSW” Practice Location

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