Basic Information
| Provider Information | |||||||||
| NPI: | 1184238354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANKO | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1785 E SAHARA AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891043759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022528342 | ||||||||
| FaxNumber: | 7022528342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1785 E SAHARA AVE STE 160 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891043759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022528342 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2020 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 1312P-S | NV | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | IC-1624 | NV | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 9097-S | NV | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.