Provider Demographics
NPI:1801898960
Name:PALANZA, MICHAEL A (LPA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:PALANZA
Suffix:
Gender:M
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 WALNUT ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4067
Mailing Address - Country:US
Mailing Address - Phone:910-251-8955
Mailing Address - Fax:910-202-4740
Practice Address - Street 1:313 WALNUT ST
Practice Address - Street 2:SUITE 105
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4067
Practice Address - Country:US
Practice Address - Phone:910-251-8955
Practice Address - Fax:910-202-4740
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2012-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2418101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107183Medicaid