Healthcare Provider Details

I. General information

NPI: 1336729987
Provider Name (Legal Business Name): MARNIE JEAN VAUGHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 LAVENDER CT
DALLAS GA
30132-0103
US

IV. Provider business mailing address

87 LAVENDER CT
DALLAS GA
30132-0103
US

V. Phone/Fax

Practice location:
  • Phone: 678-429-0405
  • Fax:
Mailing address:
  • Phone: 678-429-0405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA001826
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: