Provider Demographics
NPI:1942758644
Name:VAUGHAN, MARK ALAN (LCPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 MANTLE DR APT D
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-8379
Mailing Address - Country:US
Mailing Address - Phone:651-600-0774
Mailing Address - Fax:
Practice Address - Street 1:709 MANTLE DR APT D
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-8379
Practice Address - Country:US
Practice Address - Phone:651-600-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCPC-LIC-19032101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health