Provider Demographics
NPI:1386190353
Name:VAUGHAN, MARK (LMFT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 CENTRAL ST APT 3
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-6415
Mailing Address - Country:US
Mailing Address - Phone:619-952-8263
Mailing Address - Fax:
Practice Address - Street 1:1740 RIDGE AVE STE 305
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5909
Practice Address - Country:US
Practice Address - Phone:312-899-6184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.001204106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist