Provider Demographics
NPI:1245986603
Name:VAUGHN, BERTHA (AMFT, APCC)
Entity type:Individual
Prefix:MRS
First Name:BERTHA
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:AMFT, APCC
Other - Prefix:
Other - First Name:BERTHA
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3940 DAWES ST APT 71
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3538
Mailing Address - Country:US
Mailing Address - Phone:323-817-9627
Mailing Address - Fax:
Practice Address - Street 1:1845 CHICAGO AVE STE B
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2366
Practice Address - Country:US
Practice Address - Phone:951-465-3664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE2935267OtherDRIVERS LICENSE