Provider Demographics
NPI:1396586327
Name:GHANEM, MARYAM M
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:M
Last Name:GHANEM
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 1:1305 MARVELAND CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:FLANDERS
Mailing Address - State:NJ
Mailing Address - Zip Code:07836-4433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 MARVELAND CRESCENT ST
Practice Address - Street 2:
Practice Address - City:FLANDERS
Practice Address - State:NJ
Practice Address - Zip Code:07836-4433
Practice Address - Country:US
Practice Address - Phone:973-979-6136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ16714766472566632517103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst