Provider Demographics
NPI:1366869372
Name:VAUGHAN, JUDYTHE
Entity Type:Individual
Prefix:
First Name:JUDYTHE
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15601 ORCHARD RUN DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4608
Mailing Address - Country:US
Mailing Address - Phone:301-860-0277
Mailing Address - Fax:
Practice Address - Street 1:15601 ORCHARD RUN DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4608
Practice Address - Country:US
Practice Address - Phone:301-860-0277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3019831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical