Healthcare Provider Details

I. General information

NPI: 1720117153
Provider Name (Legal Business Name): CAMILLE SHAWNTE' VAUGHAN OTR-L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 RESERVOIR RD NW
WASHINGTON DC
20007-2113
US

IV. Provider business mailing address

10503 BAILEY DR
CHELTENHAM MD
20623-1113
US

V. Phone/Fax

Practice location:
  • Phone: 202-444-3690
  • Fax:
Mailing address:
  • Phone: 301-509-5405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number04592
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: