Provider Demographics
NPI:1184276164
Name:EZEUKA, SHANA RENEE (CCC, SLP)
Entity type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:RENEE
Last Name:EZEUKA
Suffix:
Gender:F
Credentials:CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 GUILFORD RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1406
Mailing Address - Country:US
Mailing Address - Phone:215-962-6556
Mailing Address - Fax:
Practice Address - Street 1:210 E STREET RD STE 3D
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-7680
Practice Address - Country:US
Practice Address - Phone:267-684-9084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00993100235Z00000X
PASL014619235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist