MEDICARE: VINEYARD COUNSELING, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1457200784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VINEYARD COUNSELING, LLC

Provider Business Mailing Address
First Line	:	6699 SOUTHFORK RD
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-9634
Country	:	US
Telephone Number	:	385-208-9306
Fax Number	:

Provider Business Practice Location Address
First Line	:	6699 SOUTHFORK RD
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-9634
Country	:	US
Telephone Number	:	385-208-9306
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DONNA JOANNE MORTENSEN
Credential	:	LCSW
Telephone Number	:	385-208-9306

Provider Enumeration Date	:	01/28/2026
Last Update Date	:	01/28/2026

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