Provider Demographics
NPI:1831224195
Name:VAUGHN, TERESA F (MSPT COMT)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:F
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:MSPT COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MOORES GROVE RD
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30683-1517
Mailing Address - Country:US
Mailing Address - Phone:706-742-0082
Mailing Address - Fax:
Practice Address - Street 1:105 MOORES GROVE RD
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30683-1517
Practice Address - Country:US
Practice Address - Phone:706-742-0082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005187225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA418397512AMedicaid
GA65BBDDMMedicare PIN