Provider Demographics
NPI:1386508562
Name:HIBBARD-CASAULT, MYAH NICOLE
Entity type:Individual
Prefix:
First Name:MYAH
Middle Name:NICOLE
Last Name:HIBBARD-CASAULT
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 1:15031 CARMEL LN APT 101
Mailing Address - Street 2:
Mailing Address - City:HUNTERTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46748-9194
Mailing Address - Country:US
Mailing Address - Phone:260-515-7250
Mailing Address - Fax:
Practice Address - Street 1:101 W DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1915
Practice Address - Country:US
Practice Address - Phone:260-205-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-12
Last Update Date:2025-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician