Healthcare Provider Details

I. General information

NPI: 1336986090
Provider Name (Legal Business Name): GENESIS EMILIA VAUGHN OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5086 DORSEY HALL DR
ELLICOTT CITY MD
21042-7711
US

IV. Provider business mailing address

1003 FLESTER LN
LAUREL MD
20707-6512
US

V. Phone/Fax

Practice location:
  • Phone: 240-470-0743
  • Fax:
Mailing address:
  • Phone: 240-381-6948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number10298
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: