MEDICARE: MICHELLE NICOLE GHOSH BCBA

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	103K00000X	Behavior Analyst	1-17-29091

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14259227	OTHER		CAQH

General Provider Information

NPI Number	:	1467942599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE NICOLE GHOSH BCBA

Provider Business Mailing Address
First Line	:	3500 DEPAUW BLVD STE 3070
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-6135
Country	:	US
Telephone Number	:	855-324-0885
Fax Number	:

Provider Business Practice Location Address
First Line	:	2240 36TH AVE NW
Second Line	:
City	:	NORMAN
State	:	OK
Zip	:	73072-3251
Country	:	US
Telephone Number	:	855-324-0885
Fax Number	:

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

Provider Enumeration Date	:	05/15/2018
Last Update Date	:	07/27/2022

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