Healthcare Provider Details

I. General information

NPI: 1265041214
Provider Name (Legal Business Name): SHOSHANA LEAH KANAREK LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1483 E SPRUCE ST
LAKEWOOD NJ
08701-5444
US

IV. Provider business mailing address

127 E 8TH ST
LAKEWOOD NJ
08701-2020
US

V. Phone/Fax

Practice location:
  • Phone: 732-276-5828
  • Fax:
Mailing address:
  • Phone: 848-223-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06551900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: