Provider Demographics
NPI:1174234256
Name:PACK, YVETTE GENINE (LCSW-C, CCM, NBC-HWC)
Entity type:Individual
Prefix:
First Name:YVETTE
Middle Name:GENINE
Last Name:PACK
Suffix:
Gender:F
Credentials:LCSW-C, CCM, NBC-HWC
Other - Prefix:
Other - First Name:YVETTE
Other - Middle Name:GENINE
Other - Last Name:PACK LOGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6824 SEWELLS ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4487
Mailing Address - Country:US
Mailing Address - Phone:410-381-2196
Mailing Address - Fax:
Practice Address - Street 1:6824 SEWELLS ORCHARD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4487
Practice Address - Country:US
Practice Address - Phone:443-204-4148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
702824736171400000X
MD068301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171400000XOther Service ProvidersHealth & Wellness Coach