MEDICARE: MICHELE L VINING MA, PLPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180008948	IL
2	101YP2500X	Professional Counselor	2016018719	MO

General Provider Information

NPI Number	:	1417407081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELE L VINING MA, PLPC

Provider Business Mailing Address
First Line	:	7418 FOLEY DR
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-2301
Country	:	US
Telephone Number	:	618-972-8881
Fax Number	:

Provider Business Practice Location Address
First Line	:	5016 N ILLINOIS ST
Second Line	:	SUITE A
City	:	FAIRVIEW HEIGHTS
State	:	IL
Zip	:	62208-3411
Country	:	US
Telephone Number	:	618-398-7250
Fax Number	:	618-234-6311

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2016
Last Update Date	:	10/07/2016

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