Provider Demographics
NPI:1447861497
Name:COBURN, MIKKI B (MED)
Entity type:Individual
Prefix:
First Name:MIKKI
Middle Name:B
Last Name:COBURN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:MIKKI
Other - Middle Name:
Other - Last Name:ZIMMERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:317-939-5377
Mailing Address - Fax:317-932-7880
Practice Address - Street 1:160 PLAINFIELD VILLAGE DRIVE, SUITE 101
Practice Address - Street 2:NULL
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2782
Practice Address - Country:US
Practice Address - Phone:463-888-0118
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-20-43590103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1-20-43590OtherBACB CERTIFICATION