Healthcare Provider Details

I. General information

NPI: 1962223230
Provider Name (Legal Business Name): STELLA PANOS PHD A PROFESSIONAL PSYCHOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2024
Last Update Date: 10/26/2025
Certification Date: 10/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WILSHIRE BLVD STE 204
SANTA MONICA CA
90401-1737
US

IV. Provider business mailing address

720 WILSHIRE BLVD STE 204
SANTA MONICA CA
90401-1737
US

V. Phone/Fax

Practice location:
  • Phone: 424-345-6377
  • Fax:
Mailing address:
  • Phone: 424-345-6377
  • Fax: 800-387-6076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: STELLA PANOS
Title or Position: PRESIDENT
Credential: PHD
Phone: 424-345-6377