Healthcare Provider Details

I. General information

NPI: 1215618202
Provider Name (Legal Business Name): VINE BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 REVERE AVE
DAYTON OH
45420-1722
US

IV. Provider business mailing address

2716 REVERE AVE
DAYTON OH
45420-1722
US

V. Phone/Fax

Practice location:
  • Phone: 937-751-6763
  • Fax:
Mailing address:
  • Phone: 937-751-6763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ERIKA RUSS
Title or Position: CO-FOUNDER
Credential: M.S.
Phone: 937-751-6763