Provider Demographics
NPI:1124172499
Name:RAINTREE CLINIC
Entity type:Organization
Organization Name:RAINTREE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DA
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-323-2875
Mailing Address - Street 1:804 STAMPER RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-4379
Mailing Address - Country:US
Mailing Address - Phone:910-323-2875
Mailing Address - Fax:910-323-1355
Practice Address - Street 1:804 STAMPER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4379
Practice Address - Country:US
Practice Address - Phone:910-323-2875
Practice Address - Fax:910-323-1355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50018101YA0400X
NCMHL-026-176101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty