Provider Demographics
NPI:1033130406
Name:VAUGHAN, PONZA A (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:PONZA
Middle Name:A
Last Name:VAUGHAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-3649
Mailing Address - Country:US
Mailing Address - Phone:803-432-9300
Mailing Address - Fax:803-432-9307
Practice Address - Street 1:507 WALNUT ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3649
Practice Address - Country:US
Practice Address - Phone:803-432-9300
Practice Address - Fax:803-432-9307
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC742225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1713Medicaid
SCD18255Medicare UPIN
SCQ347643560Medicare PIN
SCTH1713Medicaid