Healthcare Provider Details

I. General information

NPI: 1083504203
Provider Name (Legal Business Name): SUSAN NICOLE VAUGHN CADC-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 SE 50TH AVE
PORTLAND OR
97206-2248
US

IV. Provider business mailing address

PO BOX 86160
PORTLAND OR
97286-0160
US

V. Phone/Fax

Practice location:
  • Phone: 503-238-5203
  • Fax:
Mailing address:
  • Phone: 503-238-5203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-25-4816
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: