Provider Demographics
NPI:1265711493
Name:VAUGHN, MYRTLE (COUNSELOR)
Entity type:Individual
Prefix:MS
First Name:MYRTLE
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4308 S ASOTIN ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-2435
Mailing Address - Country:US
Mailing Address - Phone:253-473-0150
Mailing Address - Fax:253-473-1406
Practice Address - Street 1:4301 S PINE ST
Practice Address - Street 2:SUITE 30-04
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7264
Practice Address - Country:US
Practice Address - Phone:253-473-2679
Practice Address - Fax:253-473-1406
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACL 60160523101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACL60160523OtherBEHAVIORAL HEALTH