Healthcare Provider Details

I. General information

NPI: 1457944209
Provider Name (Legal Business Name): SHEILA VAUGHN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 SAN ANTONIO ST
SANTA FE NM
87505-2848
US

IV. Provider business mailing address

557 SAN ANTONIO ST
SANTA FE NM
87505-2848
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-3034
  • Fax:
Mailing address:
  • Phone: 505-629-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1294
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: