Provider Demographics
NPI:1740405299
Name:VAUGHN, WALLY GLENDALE JR (MA CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:WALLY
Middle Name:GLENDALE
Last Name:VAUGHN
Suffix:JR
Gender:M
Credentials:MA CCC-SLP
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Mailing Address - Street 1:3800 WAYNE MEMORIAL DR
Mailing Address - Street 2:APT B7
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-7379
Mailing Address - Country:US
Mailing Address - Phone:803-378-2905
Mailing Address - Fax:
Practice Address - Street 1:3800 WAYNE MEMORIAL DR
Practice Address - Street 2:APT B7
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-7379
Practice Address - Country:US
Practice Address - Phone:803-378-2905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2014-11-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NC8169235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist