Provider Demographics
NPI:1225137755
Name:ABBOTT, BRIAN VAUGHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:VAUGHN
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 GRACE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2900
Mailing Address - Country:US
Mailing Address - Phone:901-337-7765
Mailing Address - Fax:
Practice Address - Street 1:415 E UNAKA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4030
Practice Address - Country:US
Practice Address - Phone:901-337-7765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2669103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical