Healthcare Provider Details

I. General information

NPI: 1760372411
Provider Name (Legal Business Name): LIVING VINE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 CLARKTON RD
NATHALIE VA
24577-3133
US

IV. Provider business mailing address

2111 CLARKTON RD
NATHALIE VA
24577-3133
US

V. Phone/Fax

Practice location:
  • Phone: 434-830-1748
  • Fax:
Mailing address:
  • Phone: 434-830-1748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: BERKLEY ANNE CONNER
Title or Position: OWNER
Credential: LPC
Phone: 434-222-9098