Provider Demographics
NPI:1487232989
Name:PANOS, ANGELEA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANGELEA
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 1:11820 S MAPLE RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-7332
Mailing Address - Country:US
Mailing Address - Phone:801-671-5226
Mailing Address - Fax:
Practice Address - Street 1:11820 S MAPLE RIDGE CIR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-7332
Practice Address - Country:US
Practice Address - Phone:801-671-5226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT116245-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT116245-2501OtherSTATE OF UTAH: PSYCHOLOGY LICENSE