Basic Information
| Provider Information | |||||||||
| NPI: | 1790004265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANICACCI | ||||||||
| FirstName: | AMIE | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | MSW, ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1670 AMBERWOOD DR APT C | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910301930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187207701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15339 SATICOY ST | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914063345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182672646 | ||||||||
| FaxNumber: | 8182672691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2010 | ||||||||
| LastUpdateDate: | 05/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 28045 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.