Provider Demographics
NPI:1700175650
Name:VAUGHN, MARY JO ANNE (OTRL)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:ANNE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E9598 CRIMSON CT
Mailing Address - Street 2:
Mailing Address - City:WETMORE
Mailing Address - State:MI
Mailing Address - Zip Code:49895-9015
Mailing Address - Country:US
Mailing Address - Phone:906-450-3543
Mailing Address - Fax:
Practice Address - Street 1:E9598 CRIMSON CT
Practice Address - Street 2:
Practice Address - City:WETMORE
Practice Address - State:MI
Practice Address - Zip Code:49895-9015
Practice Address - Country:US
Practice Address - Phone:906-450-3543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001971225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist