Healthcare Provider Details

I. General information

NPI: 1760637219
Provider Name (Legal Business Name): WILLARD ALLEN VAUGHN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 COLISEUM XING # 6045
HAMPTON VA
23666-5971
US

IV. Provider business mailing address

110 COLISEUM XING # 6045
HAMPTON VA
23666-5971
US

V. Phone/Fax

Practice location:
  • Phone: 833-464-5438
  • Fax: 757-578-8226
Mailing address:
  • Phone: 833-464-5438
  • Fax: 757-578-8226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPRC15236
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC10487
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39003460A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701007739
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: