Healthcare Provider Details

I. General information

NPI: 1851457121
Provider Name (Legal Business Name): JOSEPH H. VAUGHN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4875 MANHATTAN DR
ROCKFORD IL
61108
US

IV. Provider business mailing address

4875 MANHATTAN DRIVE
ROCKFORD IL
61108
US

V. Phone/Fax

Practice location:
  • Phone: 815-227-4673
  • Fax: 815-227-4675
Mailing address:
  • Phone: 815-227-4673
  • Fax: 815-227-4675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSEPH H. VAUGHN
Title or Position: OWNER
Credential: PH.D.
Phone: 815-227-4673