Healthcare Provider Details

I. General information

NPI: 1275095598
Provider Name (Legal Business Name): SHIRA SHALOMCHAIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 PROSPECT ST
LAKEWOOD NJ
08701-4642
US

IV. Provider business mailing address

232 MARTIN LUTHER KING DR
LAKEWOOD NJ
08701-4844
US

V. Phone/Fax

Practice location:
  • Phone: 732-961-7413
  • Fax:
Mailing address:
  • Phone: 732-552-3824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: