=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255409058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKOLE GREATHOUSE PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2006
-----------------------------------------------------
Last Update Date | 11/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 E COLUMBIA ST
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48854-1381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-244-8930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1795 S ONONDAGA RD
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48854-9724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-581-7077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501011722
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------