1417419318 NPI number — WENDY VAUGHTER MPA,LLMSW, DP-C

Table of content: WENDY VAUGHTER MPA,LLMSW, DP-C (NPI 1417419318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417419318 NPI number — WENDY VAUGHTER MPA,LLMSW, DP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAUGHTER
Provider First Name:
WENDY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPA,LLMSW, DP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAUGHTER
Provider Other First Name:
WENDY
Provider Other Middle Name:
MONICA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPA,LLMSW,DP-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417419318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1434
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-942-1430
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2844 LIVERNOIS RD
Provider Second Line Business Practice Location Address:
UNIT 1434
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-942-1430
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6851103737 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1417419318 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 84-3172033 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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