Provider Demographics
NPI:1689479933
Name:BECKHAM, MARY ELLEN JENNIFER
Entity type:Individual
Prefix:
First Name:MARY ELLEN JENNIFER
Middle Name:
Last Name:BECKHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 RED COACH DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-8307
Mailing Address - Country:US
Mailing Address - Phone:574-387-4313
Mailing Address - Fax:574-204-2868
Practice Address - Street 1:7311 QUALITY CIR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-2014
Practice Address - Country:US
Practice Address - Phone:574-387-4313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-25-410192106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician