Provider Demographics
NPI:1447428388
Name:VAUGHN, LEANNE
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:
Last Name:VAUGHN
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 1:501 22ND ST
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064-1711
Mailing Address - Country:US
Mailing Address - Phone:304-766-7655
Mailing Address - Fax:304-755-2824
Practice Address - Street 1:9 COURTHOUSE DR
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:WV
Practice Address - Zip Code:25213-9347
Practice Address - Country:US
Practice Address - Phone:304-586-0500
Practice Address - Fax:304-586-0553
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV6758103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9203001000Medicaid