Provider Demographics
NPI:1144600982
Name:KOSTRUBANIC, MEGAN (MS, MAC)
Entity Type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:
Last Name:KOSTRUBANIC
Suffix:
Gender:F
Credentials:MS, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 N COLISEUM BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3139
Mailing Address - Country:US
Mailing Address - Phone:260-223-4613
Mailing Address - Fax:
Practice Address - Street 1:2420 N COLISEUM BLVD STE 206
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3139
Practice Address - Country:US
Practice Address - Phone:260-223-4613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
IN0474101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201315280AMedicaid