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General NPI Number Information
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NPI Number | 1780560771
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Entity Type | Organization
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Legal Business Name | VINE COUNSELING PLLC
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Dates
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Enumeration Date | 08/14/2025
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Last Update Date | 08/14/2025
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Provider Practice Location Address
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Address Line | 1136 MAIN ST
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City | LEICESTER
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State | MA
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Zip | 01524-1349
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Country | US
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Telephone | 607-207-6681
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Fax |
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Provider Business Mailing Address
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Address Line | 436 SOUTHBRIDGE ST SUITE 2 #1006
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City | AUBURN
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State | MA
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Zip | 01501
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Country | US
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Telephone | 607-207-6681
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Fax | 607-207-6681
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Authorized Official
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Title or Position | CEO
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Name | STACI LYN JACKSON
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Credential | LMFT
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Telephone | 607-207-6681
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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