Provider Demographics
NPI:1760353478
Name:VAUGHN, ETHEL MAE (CADC-R)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:MAE
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22737 NE HALSEY ST APT 146
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-4603
Mailing Address - Country:US
Mailing Address - Phone:971-274-3757
Mailing Address - Fax:
Practice Address - Street 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7514
Practice Address - Country:US
Practice Address - Phone:971-274-3757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-25-5778101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)