1710916911 NPI number — DEANNA VAUGHN VITALE LSCSW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710916911 NPI number — DEANNA VAUGHN VITALE LSCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VITALE
Provider First Name:
DEANNA
Provider Middle Name:
VAUGHN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LSCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAUGHN
Provider Other First Name:
DEANNA
Provider Other Middle Name:
RAI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710916911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4253 N CROSSOVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72703-4593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-521-5731
Provider Business Mailing Address Fax Number:
479-521-6520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10301 MAYO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARLING
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72923-1660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-494-5760
Provider Business Practice Location Address Fax Number:
479-484-8142
Provider Enumeration Date:
07/01/2006

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:  1241-C , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5Y300 . This is a "BLUE CROSS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 06070021300 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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