Healthcare Provider Details

I. General information

NPI: 1790071892
Provider Name (Legal Business Name): SUSAN E VAUGHN MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WIMBLEDON SQ STE A
CHESAPEAKE VA
23320-4931
US

IV. Provider business mailing address

100 WIMBLEDON SQ STE A
CHESAPEAKE VA
23320-4931
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-5145
  • Fax: 757-312-0216
Mailing address:
  • Phone: 757-547-5145
  • Fax: 757-312-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305002693
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: