Provider Demographics
NPI:1417419318
Name:VAUGHTER, WENDY (MPA,LLMSW, DP-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:VAUGHTER
Suffix:
Gender:F
Credentials:MPA,LLMSW, DP-C
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:MONICA
Other - Last Name:VAUGHTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPA,LLMSW,DP-C
Mailing Address - Street 1:PO BOX 1434
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099
Mailing Address - Country:US
Mailing Address - Phone:586-942-1430
Mailing Address - Fax:
Practice Address - Street 1:2844 LIVERNOIS RD
Practice Address - Street 2:UNIT 1434
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48099
Practice Address - Country:US
Practice Address - Phone:586-942-1430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511037371041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417419318Medicaid
MI84-3172033Medicaid