Provider Demographics
NPI:1548890312
Name:GINCH, WANDA EVELIZ
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:EVELIZ
Last Name:GINCH
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 1:77 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3757
Mailing Address - Country:US
Mailing Address - Phone:718-442-7828
Mailing Address - Fax:
Practice Address - Street 1:77 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3757
Practice Address - Country:US
Practice Address - Phone:718-442-7828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108558-02104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker