Provider Demographics
NPI:1689143117
Name:GANZ, CHAVA BASYA
Entity type:Individual
Prefix:
First Name:CHAVA
Middle Name:BASYA
Last Name:GANZ
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 1:6 FILLMORE AVE BSMT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5665
Mailing Address - Country:US
Mailing Address - Phone:516-273-5324
Mailing Address - Fax:
Practice Address - Street 1:1500 NJ-88
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724
Practice Address - Country:US
Practice Address - Phone:732-367-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06405100104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid