Healthcare Provider Details

I. General information

NPI: 1013146117
Provider Name (Legal Business Name): AMANDA SHANNON VAUGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2009
Last Update Date: 02/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BLACKHORSE HILL RD
COATESVILLE PA
19320-2040
US

IV. Provider business mailing address

1400 BLACKHORSE HILL RD
COATESVILLE PA
19320-2040
US

V. Phone/Fax

Practice location:
  • Phone: 610-384-7711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2232
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: