Healthcare Provider Details

I. General information

NPI: 1073710331
Provider Name (Legal Business Name): RYAN BRADLEY VAUGHAN QMHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 NW MADRAS HWY
PRINEVILLE OR
97754-1416
US

IV. Provider business mailing address

60933 CLEARMEADOW CT
BEND OR
97702-2794
US

V. Phone/Fax

Practice location:
  • Phone: 541-323-5330
  • Fax: 541-447-1121
Mailing address:
  • Phone: 541-350-1071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: