Provider Demographics
NPI:1467942599
Name:GHOSH, MICHELLE NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:GHOSH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:
Practice Address - Street 1:2240 36TH AVE NW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-3251
Practice Address - Country:US
Practice Address - Phone:855-324-0885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-29091103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
14259227OtherCAQH