Provider Demographics
NPI:1609003672
Name:GANBERG, SHELDON R (PHD, LAC)
Entity Type:Individual
Prefix:DR
First Name:SHELDON
Middle Name:R
Last Name:GANBERG
Suffix:
Gender:M
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 ANGELL AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5002
Mailing Address - Country:US
Mailing Address - Phone:204-221-0727
Mailing Address - Fax:
Practice Address - Street 1:69 ANGELL AVE
Practice Address - Street 2:APT 1
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-5002
Practice Address - Country:US
Practice Address - Phone:207-221-0727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist