Provider Demographics
NPI:1104252352
Name:PANOS, STELLA (PHD)
Entity type:Individual
Prefix:DR
First Name:STELLA
Middle Name:
Last Name:PANOS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11301 WILSHIRE BLVD BLDG 256
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073-1003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 20TH ST STE 150
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2050
Practice Address - Country:US
Practice Address - Phone:310-582-7450
Practice Address - Fax:310-582-7495
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25723103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical