Provider Demographics
NPI:1023884970
Name:CAMPBELL, MIKAYLA
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:CAMPBELL
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 1:424 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-1024
Mailing Address - Country:US
Mailing Address - Phone:317-619-6454
Mailing Address - Fax:
Practice Address - Street 1:424 N 20TH AVE
Practice Address - Street 2:
Practice Address - City:BEECH GROVE
Practice Address - State:IN
Practice Address - Zip Code:46107-1024
Practice Address - Country:US
Practice Address - Phone:317-619-6454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-01
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN373H00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician