Provider Demographics
NPI:1275025926
Name:WIMBERLEY, VAUGHAN R (LCSW-C)
Entity Type:Individual
Prefix:
First Name:VAUGHAN
Middle Name:R
Last Name:WIMBERLEY
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 BOSTON ST STE 421
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-5281
Mailing Address - Country:US
Mailing Address - Phone:410-907-7656
Mailing Address - Fax:
Practice Address - Street 1:3500 BOSTON ST STE 421
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-5281
Practice Address - Country:US
Practice Address - Phone:410-907-7656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23796104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker