Healthcare Provider Details

I. General information

NPI: 1902009038
Provider Name (Legal Business Name): S. BRUCE ROGERS-VAUGHN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5123 VIRGINIA WAY UNIT A-11
BRENTWOOD TN
37027-7519
US

IV. Provider business mailing address

5123 VIRGINIA WAY UNIT A-11
BRENTWOOD TN
37027-7519
US

V. Phone/Fax

Practice location:
  • Phone: 615-969-3083
  • Fax: 615-371-8117
Mailing address:
  • Phone: 615-969-3083
  • Fax: 615-371-8117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number0000000034
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: