Provider Demographics
NPI:1689218919
Name:GANCHROW, SHIREET (MA)
Entity Type:Individual
Prefix:
First Name:SHIREET
Middle Name:
Last Name:GANCHROW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 TAMARIND RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-3879
Mailing Address - Country:US
Mailing Address - Phone:323-509-1135
Mailing Address - Fax:
Practice Address - Street 1:2 STACY CT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2912
Practice Address - Country:US
Practice Address - Phone:323-509-1135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTL-3335235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist