Provider Demographics
NPI:1558884189
Name:DRAUGHN, VIRGINIA JANAI
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:JANAI
Last Name:DRAUGHN
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 1:26 UNITY WAY
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4109
Mailing Address - Country:US
Mailing Address - Phone:857-265-0103
Mailing Address - Fax:
Practice Address - Street 1:1115 W CHESTNUT ST STE 101
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:508-521-2287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$Medicaid