Provider Demographics
NPI:1588983308
Name:PAPA GANACHE, LLP
Entity type:Organization
Organization Name:PAPA GANACHE, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:SIROTI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:732-770-0428
Mailing Address - Street 1:25 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1508
Mailing Address - Country:US
Mailing Address - Phone:732-217-1750
Mailing Address - Fax:732-217-1749
Practice Address - Street 1:25 CHURCH ST
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1508
Practice Address - Country:US
Practice Address - Phone:732-217-1750
Practice Address - Fax:732-217-1749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC05262800251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0224031Medicaid