Provider Demographics
NPI:1396028668
Name:VAUGHN, MICHAEL SHANNON (LCSW, ADC III)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANNON
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:LCSW, ADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6997 CROW RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78263-6245
Mailing Address - Country:US
Mailing Address - Phone:210-792-4603
Mailing Address - Fax:
Practice Address - Street 1:6997 CROW RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78263-6245
Practice Address - Country:US
Practice Address - Phone:210-792-4603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15076-0899101YA0400X
TX367281041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15076-0899OtherTCBAP
TX36728OtherLCSW