Provider Demographics
NPI:1205509932
Name:VAUGHAN, PHYLLIS
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18108 CHEVAL DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1242
Mailing Address - Country:US
Mailing Address - Phone:313-909-5189
Mailing Address - Fax:
Practice Address - Street 1:20303 KELLY RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48225-1206
Practice Address - Country:US
Practice Address - Phone:313-506-9786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511070021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical