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General NPI Number Information
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NPI Number | 1700175650
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Entity Type | Individual
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Provider Name | MARY JO ANNE VAUGHN OTRL
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Gender | Female
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Dates
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Enumeration Date | 03/31/2011
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Last Update Date | 03/31/2011
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Provider Practice Location Address
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Address Line | E9598 CRIMSON CT
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City | WETMORE
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State | MI
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Zip | 49895-9015
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Country | US
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Telephone | 906-450-3543
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Fax |
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Provider Business Mailing Address
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Address Line | E9598 CRIMSON CT
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City | WETMORE
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State | MI
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Zip | 49895-9015
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Country | US
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Telephone | 906-450-3543
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 5201001971
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License Number State | MI
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