Provider Demographics
NPI:1306393368
Name:PANOSIAN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PANOSIAN
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 1:10605 BALBOA BLVD
Mailing Address - Street 2:#100
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-6342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2930 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-3411
Practice Address - Country:US
Practice Address - Phone:424-241-0407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist