=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720312721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA LYNN VAUGHAN MS, CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2009
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3750 LINDELL BLVD SAINT LOUIS UNIVERSITY
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-231-5748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 CHESAPEAKE TRL
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62236-4360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-231-5748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 2009012465
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------