Provider Demographics
NPI:1831148709
Name:VAUGHAN, SUSAN MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9126
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-9126
Mailing Address - Country:US
Mailing Address - Phone:602-870-6965
Mailing Address - Fax:602-870-8329
Practice Address - Street 1:1825 E NORTHERN AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3940
Practice Address - Country:US
Practice Address - Phone:602-870-6965
Practice Address - Fax:602-870-8329
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3149103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ68741Medicare ID - Type Unspecified