Provider Demographics
NPI:1962126201
Name:PACK, TAYLOR FELICE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:FELICE
Last Name:PACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92-1536 ALIINUI DR APT 5
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-4418
Mailing Address - Country:US
Mailing Address - Phone:808-807-4848
Mailing Address - Fax:
Practice Address - Street 1:92-1536 ALIINUI DR APT 5
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-4418
Practice Address - Country:US
Practice Address - Phone:808-807-4848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-21-174323103K00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst