Provider Demographics
NPI:1346096815
Name:VAUGHN, MARSHALL ALEXANDER
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:ALEXANDER
Last Name:VAUGHN
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 1:8612 SALISH RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-1904
Mailing Address - Country:US
Mailing Address - Phone:909-414-8049
Mailing Address - Fax:
Practice Address - Street 1:555 PARKCENTER DR STE 115
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3521
Practice Address - Country:US
Practice Address - Phone:888-745-6153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty