Healthcare Provider Details

I. General information

NPI: 1265711493
Provider Name (Legal Business Name): MYRTLE VAUGHN COUNSELOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2011
Last Update Date: 08/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 S PINE ST SUITE 30-04
TACOMA WA
98409-7264
US

IV. Provider business mailing address

4308 S ASOTIN ST
TACOMA WA
98418-2435
US

V. Phone/Fax

Practice location:
  • Phone: 253-473-2679
  • Fax: 253-473-1406
Mailing address:
  • Phone: 253-473-0150
  • Fax: 253-473-1406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCL 60160523
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: