Provider Demographics
NPI:1215272083
Name:PANZA, ALICIA SUSAN (MA)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:SUSAN
Last Name:PANZA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:ALICIA
Other - Middle Name:SUSAN
Other - Last Name:PANZA CLARK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:3808 ZIEBER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-2636
Mailing Address - Country:US
Mailing Address - Phone:707-477-3477
Mailing Address - Fax:
Practice Address - Street 1:3808 ZIEBER RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-2636
Practice Address - Country:US
Practice Address - Phone:707-477-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst