Provider Demographics
NPI:1417766007
Name:VAUGHN, DESAREA
Entity type:Individual
Prefix:
First Name:DESAREA
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:DEZMOND
Other - Middle Name:
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2665 RIDGECROFT DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3290 W BIG BEAVER RD STE 510
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-2917
Practice Address - Country:US
Practice Address - Phone:734-513-2731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician