Provider Demographics
NPI:1710916911
Name:VITALE, DEANNA VAUGHN (LSCSW)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:VAUGHN
Last Name:VITALE
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:RAI
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4253 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4593
Mailing Address - Country:US
Mailing Address - Phone:479-521-5731
Mailing Address - Fax:479-521-6520
Practice Address - Street 1:10301 MAYO DR
Practice Address - Street 2:
Practice Address - City:BARLING
Practice Address - State:AR
Practice Address - Zip Code:72923-1660
Practice Address - Country:US
Practice Address - Phone:479-494-5760
Practice Address - Fax:479-484-8142
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1241-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y300OtherBLUE CROSS
AR06070021300OtherQUALCHOICE
AR5Y300OtherBLUE CROSS