MEDICARE: DOMINIC ROBERT GREENOUGH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1699468405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIC ROBERT GREENOUGH

Provider Business Mailing Address
First Line	:	3667 SHANLEY RD
Second Line	:
City	:	PETOSKEY
State	:	MI
Zip	:	49770-9558
Country	:	US
Telephone Number	:	989-906-5389
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 SPRING ST STE 4
Second Line	:
City	:	PETOSKEY
State	:	MI
Zip	:	49770-2881
Country	:	US
Telephone Number	:	231-268-0007
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2023
Last Update Date	:	05/29/2023

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Directions to “ DOMINIC ROBERT GREENOUGH ” Practice Location

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