Provider Demographics
NPI:1720151145
Name:CHAN, ALICE MAN (AUD)
Entity type:Individual
Prefix:DR
First Name:ALICE
Middle Name:MAN
Last Name:CHAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:MAN YING
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:202 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11363-1118
Mailing Address - Country:US
Mailing Address - Phone:718-428-2380
Mailing Address - Fax:718-353-5626
Practice Address - Street 1:139 CENTRE ST
Practice Address - Street 2:SUITE 803
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4408
Practice Address - Country:US
Practice Address - Phone:212-406-1968
Practice Address - Fax:212-431-1044
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001433237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001433OtherSTATE LICENSE NUMBER
NY01690055Medicaid
NY01690055Medicaid
NYS07876Medicare UPIN