MEDICARE: SHOSHANA RAIZEL COHEN BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-22-60981	NJ

General Provider Information

NPI Number	:	1043928377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHOSHANA RAIZEL COHEN BCBA

Provider Business Mailing Address
First Line	:	845 WOODLAND DR
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-3038
Country	:	US
Telephone Number	:	732-901-0018
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 FLANNERY AVE
Second Line	:
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701-4750
Country	:	US
Telephone Number	:	917-589-0036
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2022
Last Update Date	:	11/07/2022

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