Provider Demographics
NPI:1932199445
Name:PACK, KARYN LEIGH (OT/L)
Entity type:Individual
Prefix:
First Name:KARYN
Middle Name:LEIGH
Last Name:PACK
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 KUSZMAUL AVE NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-1257
Mailing Address - Country:US
Mailing Address - Phone:330-259-7564
Mailing Address - Fax:
Practice Address - Street 1:4200 STATE RD
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-6017
Practice Address - Country:US
Practice Address - Phone:440-576-9023
Practice Address - Fax:440-576-3065
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03584225X00000X
1021100635225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHO3584OtherOT PT ATC BOARD
OHO3584OtherOT PT ATC BOARD