Provider Demographics
NPI:1104649979
Name:MASHBURN, MYRASUE GAIL
Entity type:Individual
Prefix:
First Name:MYRASUE
Middle Name:GAIL
Last Name:MASHBURN
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 1:715 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-2905
Mailing Address - Country:US
Mailing Address - Phone:931-279-2653
Mailing Address - Fax:
Practice Address - Street 1:715 2ND ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-2905
Practice Address - Country:US
Practice Address - Phone:931-279-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst