MEDICARE: NICHOL GREATHOUSE

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	RBT-21-156460	IN

General Provider Information

NPI Number	:	1336926120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOL GREATHOUSE

Provider Business Mailing Address
First Line	:	3500 DEPAUW BLVD STE 3070
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-6135
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4422 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-6917
Country	:	US
Telephone Number	:	260-471-9263
Fax Number	:

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

Provider Enumeration Date	:	09/13/2023
Last Update Date	:	01/14/2026

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Directions to “ NICHOL GREATHOUSE ” Practice Location

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