Provider Demographics
NPI:1881100519
Name:PACK, DUSTY (LPC)
Entity type:Individual
Prefix:
First Name:DUSTY
Middle Name:
Last Name:PACK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 SPAULDING ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2640
Mailing Address - Country:US
Mailing Address - Phone:307-751-4235
Mailing Address - Fax:
Practice Address - Street 1:1898 FORT RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-8320
Practice Address - Country:US
Practice Address - Phone:307-675-3891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-1702101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional