Provider Demographics
NPI:1427557396
Name:MOON-PANAGIOTES, VIRGINIA
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:
Last Name:MOON-PANAGIOTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:R
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2123
Mailing Address - Street 2:
Mailing Address - City:HOMELAND
Mailing Address - State:CA
Mailing Address - Zip Code:92548-2123
Mailing Address - Country:US
Mailing Address - Phone:949-922-0712
Mailing Address - Fax:
Practice Address - Street 1:33276 HOMESTEAD LN
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-9169
Practice Address - Country:US
Practice Address - Phone:951-254-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
CA811151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA81115Medicaid