Provider Demographics
NPI:1902968811
Name:PACK, DELMAR GLEN (PA)
Entity Type:Individual
Prefix:
First Name:DELMAR
Middle Name:GLEN
Last Name:PACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 BRIARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763
Mailing Address - Country:US
Mailing Address - Phone:386-774-6366
Mailing Address - Fax:
Practice Address - Street 1:810 BRIARWOOD CT
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763
Practice Address - Country:US
Practice Address - Phone:386-956-1689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6914103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU5392AMedicare ID - Type Unspecified