Provider Demographics
NPI:1578537692
Name:PANOPOULOS, GEORGIA E (PHD, LP)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:E
Last Name:PANOPOULOS
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13911 RIDGEDALE DRIVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1775
Mailing Address - Country:US
Mailing Address - Phone:612-360-5108
Mailing Address - Fax:952-487-0483
Practice Address - Street 1:2621 GREENHAVEN RD
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-5566
Practice Address - Country:US
Practice Address - Phone:763-587-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4025103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN571513000Medicaid