Provider Demographics
NPI:1538404280
Name:GANSKE, SHEREE (LMT)
Entity type:Individual
Prefix:
First Name:SHEREE
Middle Name:
Last Name:GANSKE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-4915
Mailing Address - Country:US
Mailing Address - Phone:530-314-1724
Mailing Address - Fax:
Practice Address - Street 1:2520 LAKE TAHOE BLVD STE 5
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7726
Practice Address - Country:US
Practice Address - Phone:530-314-1724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT 5570225700000X
CACAMTC 28155225700000X
FLMA58085225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist