Provider Demographics
NPI:1780484055
Name:NELSON, MEKAYLA RAELYN ZALIRA
Entity type:Individual
Prefix:
First Name:MEKAYLA
Middle Name:RAELYN ZALIRA
Last Name:NELSON
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 1:1269 W 52ND DR APT J234
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-1227
Mailing Address - Country:US
Mailing Address - Phone:219-231-6470
Mailing Address - Fax:
Practice Address - Street 1:6564 PAN AM DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5100
Practice Address - Country:US
Practice Address - Phone:219-231-6470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician