MEDICARE: THE VINE COUNSELING SERVICES, LLC

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1265133391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE VINE COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	3310 MCRAE DR
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36695-5218
Country	:	US
Telephone Number	:	251-604-1995
Fax Number	:

Provider Business Practice Location Address
First Line	:	7268 COTTAGE HILL RD
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36695-2825
Country	:	US
Telephone Number	:	251-301-6855
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DANA WATSON
Credential	:	PHD, LICSW
Telephone Number	:	251-604-1995

Provider Enumeration Date	:	03/15/2023
Last Update Date	:	03/15/2023

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