Provider Demographics
NPI:1043302441
Name:GAMBLE, SHANA (MS, SLP)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-3125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1606
Practice Address - Country:US
Practice Address - Phone:697-736-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015781-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist