Provider Demographics
NPI:1205121720
Name:PANZER-FAVARA, STACI M
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:M
Last Name:PANZER-FAVARA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:STACI
Other - Middle Name:M
Other - Last Name:PANZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:280 MADISON AVE
Mailing Address - Street 2:SUITE 610
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-0801
Mailing Address - Country:US
Mailing Address - Phone:191-758-9120
Mailing Address - Fax:
Practice Address - Street 1:280 MADISON AVE
Practice Address - Street 2:SUITE 610
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-0801
Practice Address - Country:US
Practice Address - Phone:191-758-9120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR059331-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical