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General NPI Number Information
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NPI Number | 1366411290
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Entity Type | Individual
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Provider Name | FREDDIE DEAN VINES
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Gender | Male
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Dates
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Enumeration Date | 03/14/2006
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Last Update Date | 01/17/2008
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Provider Practice Location Address
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Address Line | 703 THIMBLE SHOALS BLVD A-3
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City | NEWPORT NEWS
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State | VA
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Zip | 23606-2576
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Country | US
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Telephone | 757-873-2307
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Fax |
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Provider Business Mailing Address
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Address Line | 8589 E CREEK LN
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City | HAYES
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State | VA
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Zip | 23072-3748
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Country | US
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Telephone | 757-873-2307
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0904002078
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License Number State | VA
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