Provider Demographics
NPI:1225257900
Name:GORDON, VAUGHN
Entity Type:Individual
Prefix:
First Name:VAUGHN
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 762
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:SD
Mailing Address - Zip Code:57551-0762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 ELK ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7351
Practice Address - Country:US
Practice Address - Phone:605-343-7262
Practice Address - Fax:605-343-7293
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1159101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4993249OtherBLUE CROSS/BLUE SHIELD