Healthcare Provider Details

I. General information

NPI: 1164582896
Provider Name (Legal Business Name): KENNETH A VAUGHN JR. RC CADC I CRM QMHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 HAROLD DR NE
SALEM OR
97305-1339
US

IV. Provider business mailing address

3325 HAROLD DR NE
SALEM OR
97305-1339
US

V. Phone/Fax

Practice location:
  • Phone: 503-363-2021
  • Fax: 503-363-4820
Mailing address:
  • Phone: 503-363-2021
  • Fax: 503-363-4820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number08-06-73
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRC00052879
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberQMHA
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: