Provider Demographics
NPI:1508132416
Name:GANCA, LAUREN MICHELE
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:MICHELE
Last Name:GANCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MICHELE
Other - Last Name:GANCA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:22055 46TH AVE
Mailing Address - Street 2:APT. 2Y
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3601
Mailing Address - Country:US
Mailing Address - Phone:718-428-5683
Mailing Address - Fax:
Practice Address - Street 1:5820 UTOPIA PKWY
Practice Address - Street 2:ROOM 341
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1529
Practice Address - Country:US
Practice Address - Phone:718-281-8299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-25
Last Update Date:2012-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011016-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist