Healthcare Provider Details

I. General information

NPI: 1659259778
Provider Name (Legal Business Name): MYKENZIE STANLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W LINCOLN AVE
GOSHEN IN
46526-2430
US

IV. Provider business mailing address

215 RED COACH DR
MISHAWAKA IN
46545-8307
US

V. Phone/Fax

Practice location:
  • Phone: 574-387-4313
  • Fax:
Mailing address:
  • Phone: 574-387-4313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-464794
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: