Provider Demographics
NPI:1891079711
Name:CHAN, SHAN SHAN
Entity Type:Individual
Prefix:
First Name:SHAN
Middle Name:SHAN
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 SAUNDERS ST
Mailing Address - Street 2:APT C16
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3249
Mailing Address - Country:US
Mailing Address - Phone:646-753-2112
Mailing Address - Fax:
Practice Address - Street 1:6420 SAUNDERS ST
Practice Address - Street 2:APT C16
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3249
Practice Address - Country:US
Practice Address - Phone:646-753-2112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021269-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist