Provider Demographics
NPI:1700036399
Name:VAUGHN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:VAUGHN
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 1:6700 TOTEM BEACH RD
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271-9714
Mailing Address - Country:US
Mailing Address - Phone:360-716-4096
Mailing Address - Fax:
Practice Address - Street 1:6700 TOTEM BEACH RD
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271-9714
Practice Address - Country:US
Practice Address - Phone:360-716-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005701101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH00005701OtherWASHINGTON STATE DEPARTMENT OF HEALTH LICENSED MENTAL HEALTH COUNSELOR