Provider Demographics
NPI:1043102288
Name:GANICHE, BECKER (PMHNP- BC)
Entity type:Individual
Prefix:
First Name:BECKER
Middle Name:
Last Name:GANICHE
Suffix:
Gender:M
Credentials:PMHNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LARCH AVE
Mailing Address - Street 2:
Mailing Address - City:BOGOTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07603-1010
Mailing Address - Country:US
Mailing Address - Phone:201-220-9496
Mailing Address - Fax:
Practice Address - Street 1:400 LARCH AVE
Practice Address - Street 2:
Practice Address - City:BOGOTA
Practice Address - State:NJ
Practice Address - Zip Code:07603-1010
Practice Address - Country:US
Practice Address - Phone:201-220-9496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15369100363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health