Provider Demographics
NPI:1679216790
Name:VAUGHT, RAVEN SYMONE (LISW-CP)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:SYMONE
Last Name:VAUGHT
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 SANDRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-7504
Mailing Address - Country:US
Mailing Address - Phone:803-272-8055
Mailing Address - Fax:
Practice Address - Street 1:1330 TAYLOR STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29220-5869
Practice Address - Country:US
Practice Address - Phone:803-272-8055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-16
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC150391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical