Healthcare Provider Details

I. General information

NPI: 1255576765
Provider Name (Legal Business Name): MRS. DESHRA MICHELLE VINES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 WATCH HILL DR
FLINT MI
48507-5625
US

IV. Provider business mailing address

714 LIPPINCOTT BLVD
FLINT MI
48503-5818
US

V. Phone/Fax

Practice location:
  • Phone: 810-233-6696
  • Fax: 810-233-6696
Mailing address:
  • Phone: 810-233-6696
  • Fax: 810-233-6696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberBCBA1349277
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberAS2504124845
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: