Healthcare Provider Details

I. General information

NPI: 1174090997
Provider Name (Legal Business Name): LEAH M VAUGHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 W NEPESSING ST STE 300
LAPEER MI
48446-2089
US

IV. Provider business mailing address

443 N STATE ST
CARO MI
48723-1539
US

V. Phone/Fax

Practice location:
  • Phone: 810-667-4500
  • Fax: 810-667-4512
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094634
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: