Healthcare Provider Details

I. General information

NPI: 1730061029
Provider Name (Legal Business Name): MACKENZIE LYNN SHAUL ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2025
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7203 E US HIGHWAY 36
AVON IN
46123-7967
US

IV. Provider business mailing address

1292 BIRCHWOOD WAY
GREENWOOD IN
46143-7342
US

V. Phone/Fax

Practice location:
  • Phone: 317-544-6000
  • Fax:
Mailing address:
  • Phone: 317-413-9093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number000039132
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: