Provider Demographics
NPI:1174998959
Name:VAUGHN, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 CIFAX RD
Mailing Address - Street 2:
Mailing Address - City:GOODE
Mailing Address - State:VA
Mailing Address - Zip Code:24556-2896
Mailing Address - Country:US
Mailing Address - Phone:979-824-6349
Mailing Address - Fax:
Practice Address - Street 1:2365 CIFAX RD
Practice Address - Street 2:
Practice Address - City:GOODE
Practice Address - State:VA
Practice Address - Zip Code:24556-2896
Practice Address - Country:US
Practice Address - Phone:979-824-6349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-05
Last Update Date:2015-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006370101YP2500X
VA0717001360106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist