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General NPI Number Information
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NPI Number | 1790922250
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Entity Type | Organization
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Legal Business Name | THE VINE CHRISTIAN COUNSELING, LLC
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Dates
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Enumeration Date | 01/20/2009
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Last Update Date | 01/03/2011
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Provider Practice Location Address
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Address Line | 995 PRINCE FREDERICK BLVD SUITE 209
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678-3198
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Country | US
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Telephone | 410-610-6602
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Fax |
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Provider Business Mailing Address
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Address Line | 995 PRINCE FREDERICK BLVD STE 209
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City | PRINCE FREDERICK
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State | MD
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Zip | 20678-5101
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Country | US
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Telephone | 410-610-6602
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Fax | 410-535-2226
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. TAMERA IRELAND OLSON
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Credential | LCSW-C
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Telephone | 410-610-6602
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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 | 14382
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License Number State | MD
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