Provider Demographics
NPI:1821004128
Name:DONOVAN-VAUGHN, DIANE (MFT LADC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DONOVAN-VAUGHN
Suffix:
Gender:F
Credentials:MFT LADC
Other - Prefix:
Other - First Name:B
Other - Middle Name:DIANE
Other - Last Name:DONOVAN-VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFT LADC PC
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:DECATURVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38329-0729
Mailing Address - Country:US
Mailing Address - Phone:702-256-6090
Mailing Address - Fax:702-256-1310
Practice Address - Street 1:8440 W LAKE MEAD BLVD STE 212
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7648
Practice Address - Country:US
Practice Address - Phone:702-256-6090
Practice Address - Fax:731-549-2504
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMFT0371106H00000X
NVLADC 332101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
A934671OtherVALUE OPTIONS