Provider Demographics
NPI:1235408311
Name:GANZ, ILENE S (MA CCC/SP)
Entity Type:Individual
Prefix:MRS
First Name:ILENE
Middle Name:S
Last Name:GANZ
Suffix:
Gender:F
Credentials:MA CCC/SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1328
Mailing Address - Country:US
Mailing Address - Phone:516-568-6130
Mailing Address - Fax:
Practice Address - Street 1:1475 HOWELL RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-1328
Practice Address - Country:US
Practice Address - Phone:516-568-6130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003262-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist