Provider Demographics
NPI:1710497565
Name:PANAGOPOULOS, GEORGIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGIA
Middle Name:
Last Name:PANAGOPOULOS
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 1:530 E 72ND ST APT 7B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4844
Mailing Address - Country:US
Mailing Address - Phone:212-628-9039
Mailing Address - Fax:
Practice Address - Street 1:530 EAST 72ND STREET
Practice Address - Street 2:APT 7B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4844
Practice Address - Country:US
Practice Address - Phone:212-628-9039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009595103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS09595-0OtherWORKERS COMPENSATION AUTHORIZATION NUMBER