Basic Information
| Provider Information | |||||||||
| NPI: | 1588713986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAUGHN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 W WACKER DRIVE | ||||||||
| Address2: | SUITE 1020 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606061216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126400329 | ||||||||
| FaxNumber: | 3126400407 | ||||||||
| Practice Location | |||||||||
| Address1: | 3160 8TH ST SW | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | ALTOONA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500091023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159674580 | ||||||||
| FaxNumber: | 5159674899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070-001801 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 01243 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 070-001801 | 01 | IL | PT STATE LICENSE # | OTHER |