Provider Demographics
NPI:1710138516
Name:GREATHOUSE, NICOLE SUSAN
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:SUSAN
Last Name:GREATHOUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:SUSAN
Other - Last Name:TARDIF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3019 LAZLO LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-7312
Mailing Address - Country:US
Mailing Address - Phone:321-662-3777
Mailing Address - Fax:
Practice Address - Street 1:3019 LAZLO LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-7312
Practice Address - Country:US
Practice Address - Phone:321-662-3777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-10
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4640235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist