Provider Demographics
NPI:1982685012
Name:VAUGHAN, BRENDA GALE (LISW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:GALE
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 N CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6407
Mailing Address - Country:US
Mailing Address - Phone:843-873-1592
Mailing Address - Fax:843-871-2936
Practice Address - Street 1:435 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6407
Practice Address - Country:US
Practice Address - Phone:843-873-1592
Practice Address - Fax:843-871-2936
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4738104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ34146Medicare UPIN