Provider Demographics
NPI:1164651253
Name:PANOS, SAMM HARPER
Entity type:Individual
Prefix:MISS
First Name:SAMM
Middle Name:HARPER
Last Name:PANOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-1091
Mailing Address - Fax:520-682-4132
Practice Address - Street 1:13395 N MARANA MAIN ST BLDG B
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-7008
Practice Address - Country:US
Practice Address - Phone:520-682-1091
Practice Address - Fax:520-682-4132
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YM0800X
AZLMFT-10161106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health