Provider Demographics
NPI:1194477562
Name:SHURN, MICKAYLA D
Entity type:Individual
Prefix:MS
First Name:MICKAYLA
Middle Name:D
Last Name:SHURN
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 1:6155 W JAMISON DR
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-6300
Mailing Address - Country:US
Mailing Address - Phone:317-292-5123
Mailing Address - Fax:
Practice Address - Street 1:6155 W JAMISON DR
Practice Address - Street 2:
Practice Address - City:MCCORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46055-6300
Practice Address - Country:US
Practice Address - Phone:317-292-5123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0003159Medicaid