Provider Demographics
NPI:1992078356
Name:PAINE, ANKA LASZLO
Entity type:Individual
Prefix:DR
First Name:ANKA
Middle Name:LASZLO
Last Name:PAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1366
Mailing Address - Country:US
Mailing Address - Phone:415-302-7305
Mailing Address - Fax:
Practice Address - Street 1:412 RED HILL AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2450
Practice Address - Country:US
Practice Address - Phone:415-302-7305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20691103TB0200X, 103TC1900X
20691103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily