=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598653115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VINE COUNSELING COMPANY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2025
-----------------------------------------------------
Last Update Date | 06/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 MAINE ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62301-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-336-7792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 MAINE ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62301-4036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-336-7792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELING DIRECTOR
-----------------------------------------------------
Name | MRS. JESSICA ELLEFRITZ
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 217-773-2728
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------