MEDICARE: MR. VINSON LEE LMFT

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	106H00000X	Marriage & Family Therapist	MFT001472	GA

General Provider Information

NPI Number	:	1578007704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VINSON LEE LMFT

Provider Business Mailing Address
First Line	:	3120 N OAK STREET EXT
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-5909
Country	:	US
Telephone Number	:	229-671-6170
Fax Number	:	229-671-6761

Provider Business Practice Location Address
First Line	:	3120 N OAK STREET EXT
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31602-5909
Country	:	US
Telephone Number	:	229-671-6170
Fax Number	:	229-671-6761

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

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	12/07/2016

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