Provider Demographics
NPI:1972089209
Name:PACKER, KASSONDRA NICOLE (BCABA)
Entity type:Individual
Prefix:
First Name:KASSONDRA
Middle Name:NICOLE
Last Name:PACKER
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1851
Mailing Address - Country:US
Mailing Address - Phone:704-522-9912
Mailing Address - Fax:704-566-6050
Practice Address - Street 1:716 MARSH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-1851
Practice Address - Country:US
Practice Address - Phone:704-522-9912
Practice Address - Fax:704-566-6050
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-18-9222106E00000X
NC0-18-9222106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst