MEDICARE: DR. DARA LYNN VINES PH.D.

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	103TC0700X	Clinical Psychologist	PSY11577	CA

General Provider Information

NPI Number	:	1699864777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARA LYNN VINES PH.D.

Provider Business Mailing Address
First Line	:	5935 S GARTH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90056-1513
Country	:	US
Telephone Number	:	310-216-0505
Fax Number	:	310-216-0505

Provider Business Practice Location Address
First Line	:	2566 OVERLAND AVE
Second Line	:	SUITE 500A
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-3366
Country	:	US
Telephone Number	:	310-216-0505
Fax Number	:	310-216-0505

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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