Provider Demographics
NPI:1902687064
Name:VAUGHAN, ABIGAIL GRACE (N/A)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:GRACE
Last Name:VAUGHAN
Suffix:
Gender:
Credentials:N/A
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:N/A
Mailing Address - Street 1:1360 CADUCEUS WAY
Mailing Address - Street 2:BLD 600 STE 101
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677
Mailing Address - Country:US
Mailing Address - Phone:762-499-3476
Mailing Address - Fax:
Practice Address - Street 1:1360 CADUCEUS WAY
Practice Address - Street 2:BLD 600 STE 101
Practice Address - City:WAKTINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677
Practice Address - Country:US
Practice Address - Phone:762-499-3476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-13
Last Update Date:2025-03-13
Deactivation Date:2025-03-03
Deactivation Code:
Reactivation Date:2025-03-13
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-288793106S00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician