Provider Demographics
NPI:1700908191
Name:VAUGHN, MARY A (MS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 GREY TWIG LN
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-4985
Mailing Address - Country:US
Mailing Address - Phone:954-341-0090
Mailing Address - Fax:954-341-2252
Practice Address - Street 1:2600 GREY TWIG LN
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-4985
Practice Address - Country:US
Practice Address - Phone:954-341-0090
Practice Address - Fax:954-341-2252
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4548235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist