Provider Demographics
NPI:1033963517
Name:PACK, LAURA BETH (LPC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
Last Name:PACK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:BETH
Other - Last Name:DALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:770 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1187
Mailing Address - Country:US
Mailing Address - Phone:276-223-3200
Mailing Address - Fax:276-223-0617
Practice Address - Street 1:750 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1046
Practice Address - Country:US
Practice Address - Phone:276-223-3201
Practice Address - Fax:276-625-0117
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701013403101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional