Provider Demographics
NPI:1689210791
Name:VAUGHN, ALEXIS TIERRA (CMM)
Entity type:Individual
Prefix:MRS
First Name:ALEXIS
Middle Name:TIERRA
Last Name:VAUGHN
Suffix:
Gender:F
Credentials:CMM
Other - Prefix:MS
Other - First Name:ALEXIS
Other - Middle Name:TIERRA
Other - Last Name:SMALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4420 BOSTIC DR APT 306
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-9423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4420 BOSTIC DR APT 306
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-9423
Practice Address - Country:US
Practice Address - Phone:229-379-8873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-24
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician