Healthcare Provider Details

I. General information

NPI: 1609506864
Provider Name (Legal Business Name): ETHAN VAUGHN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2022
Last Update Date: 06/12/2022
Certification Date: 06/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3646 MOUNT ELLIOTT ST
DETROIT MI
48207-2311
US

IV. Provider business mailing address

2126 LAKEVIEW DR APT 200
YPSILANTI MI
48198-6729
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-3435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851114171
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: