MEDICARE: OLIVIA VAUGHAN RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-20-145096	TX

General Provider Information

NPI Number	:	1255934618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVIA VAUGHAN RBT

Provider Business Mailing Address
First Line	:	2525 MINNESOTA AVE
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23513-4530
Country	:	US
Telephone Number	:	423-813-0424
Fax Number	:

Provider Business Practice Location Address
First Line	:	1108 EDEN WAY N
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-3339
Country	:	US
Telephone Number	:	703-596-9332
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2020
Last Update Date	:	08/21/2023

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