Provider Demographics
NPI:1609953447
Name:VAUGHAN, KENNETH HAROLD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:HAROLD
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TIN HOUSE ROAD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9735
Mailing Address - Country:US
Mailing Address - Phone:609-259-6200
Mailing Address - Fax:609-259-6288
Practice Address - Street 1:3 SOUTH MAIN STREET
Practice Address - Street 2:SUITE #6
Practice Address - City:ALLENTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08501
Practice Address - Country:US
Practice Address - Phone:609-259-6200
Practice Address - Fax:609-259-6288
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00380100103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
232446000OtherMAGELLAN
342277OtherTRICARE
084838Medicare ID - Type Unspecified