Provider Demographics
NPI:1255897294
Name:GREATHOUSE, WILLETTA T
Entity type:Individual
Prefix:
First Name:WILLETTA
Middle Name:T
Last Name:GREATHOUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11460 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-4530
Mailing Address - Country:US
Mailing Address - Phone:317-805-2316
Mailing Address - Fax:317-428-1032
Practice Address - Street 1:11460 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4530
Practice Address - Country:US
Practice Address - Phone:178-052-3163
Practice Address - Fax:317-428-1032
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6787043035OtherCREDENTIALING