MEDICARE: DANIELLE C PACK RBT

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	106S00000X	Behavior Technician	RBT-25-449938	OK

General Provider Information

NPI Number	:	1912897141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE C PACK RBT

Provider Business Mailing Address
First Line	:	330 W EDMOND RD
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003-5600
Country	:	US
Telephone Number	:	405-216-3391
Fax Number	:	405-216-3391

Provider Business Practice Location Address
First Line	:	3635 NW 39TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-6309
Country	:	US
Telephone Number	:	704-519-8360
Fax Number	:

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

Provider Enumeration Date	:	07/08/2025
Last Update Date	:	03/04/2026

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