Provider Demographics
NPI:1013042605
Name:VAUGHN, MARY (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 STATE ROUTE 162
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8500
Mailing Address - Country:US
Mailing Address - Phone:618-288-5711
Mailing Address - Fax:618-288-4088
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8500
Practice Address - Country:US
Practice Address - Phone:618-288-5711
Practice Address - Fax:618-288-4088
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILMV83270700POtherEARLY INTERVENTION