Provider Demographics
NPI:1073347407
Name:SHULL, KATIE ANN (LCMHA)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:ANN
Last Name:SHULL
Suffix:
Gender:F
Credentials:LCMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5709 N STATE ROAD 101
Mailing Address - Street 2:
Mailing Address - City:WOODBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46797-9655
Mailing Address - Country:US
Mailing Address - Phone:260-257-0016
Mailing Address - Fax:
Practice Address - Street 1:4630 W JEFFERSON BLVD STE 3
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6800
Practice Address - Country:US
Practice Address - Phone:260-632-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88002538A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health