Healthcare Provider Details

I. General information

NPI: 1619703600
Provider Name (Legal Business Name): BRITTANI VINES THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57131 LAKEVIEW RD
BAKER CA
92309
US

IV. Provider business mailing address

PO BOX 70
REDLANDS CA
92373-0021
US

V. Phone/Fax

Practice location:
  • Phone: 909-389-8582
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: