Provider Demographics
NPI:1104674779
Name:VAUGHN, KELLIE MADISON (LSW, LMSW)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MADISON
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:LSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 CHESTNUT RIDGE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:WOODCLIFF LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07677-7667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:595 CHESTNUT RIDGE RD STE 4
Practice Address - Street 2:
Practice Address - City:WOODCLIFF LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07677-7667
Practice Address - Country:US
Practice Address - Phone:551-368-0307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL07280400104100000X, 1041C0700X
NY128018104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker