Provider Demographics
NPI:1790138998
Name:VAUGHAN, MARY (CADC I)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 E ROBERTS AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-6541
Mailing Address - Country:US
Mailing Address - Phone:559-274-5543
Mailing Address - Fax:
Practice Address - Street 1:2445 W WHITES BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706-1225
Practice Address - Country:US
Practice Address - Phone:559-264-2551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA101YA04000X324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)