Provider Demographics
NPI:1639314008
Name:VAUGHANS, KIRKLAND C
Entity Type:Individual
Prefix:
First Name:KIRKLAND
Middle Name:C
Last Name:VAUGHANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-4202
Mailing Address - Country:US
Mailing Address - Phone:631-643-0615
Mailing Address - Fax:
Practice Address - Street 1:1840 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7932
Practice Address - Country:US
Practice Address - Phone:631-647-7885
Practice Address - Fax:631-647-7885
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010404-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical