Provider Demographics
NPI:1689253502
Name:GRANITZ, NATHAN A
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:GRANITZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5753 WHITE PINE RD
Mailing Address - Street 2:
Mailing Address - City:WHITESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46075-9715
Mailing Address - Country:US
Mailing Address - Phone:630-945-8454
Mailing Address - Fax:
Practice Address - Street 1:5753 WHITE PINE RD
Practice Address - Street 2:
Practice Address - City:WHITESTOWN
Practice Address - State:IN
Practice Address - Zip Code:46075-9715
Practice Address - Country:US
Practice Address - Phone:630-945-8454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001179A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health