Provider Demographics
NPI:1124676457
Name:VAUGHAN, ANGELA NICOLE (MED BCBA)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:NICOLE
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:MED BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 SAM RITTENBERG BLVD STE 1B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4125
Mailing Address - Country:US
Mailing Address - Phone:888-547-2250
Mailing Address - Fax:
Practice Address - Street 1:1529 SAM RITTENBERG BLVD STE 1B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4125
Practice Address - Country:US
Practice Address - Phone:888-547-2250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst