MEDICARE: MRS. RICHELLE CRISTIE VINING-GONZALEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LH61568740	WA

General Provider Information

NPI Number	:	1134930308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. RICHELLE CRISTIE VINING-GONZALEZ

Provider Business Mailing Address
First Line	:	1602 SUMMIT LAKE SHORE RD NW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-9437
Country	:	US
Telephone Number	:	360-259-8112
Fax Number	:

Provider Business Practice Location Address
First Line	:	1602 SUMMIT LAKE SHORE RD NW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-9437
Country	:	US
Telephone Number	:	360-259-8112
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2025
Last Update Date	:	01/16/2025

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