MEDICARE: THE VINE CHRISTIAN 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	1041C0700X	Clinical Social Worker	14382	MD

General Provider Information

NPI Number	:	1790922250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE VINE CHRISTIAN COUNSELING, LLC

Provider Business Mailing Address
First Line	:	995 PRINCE FREDERICK BLVD STE 209
Second Line	:
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-5101
Country	:	US
Telephone Number	:	410-610-6602
Fax Number	:	410-535-2226

Provider Business Practice Location Address
First Line	:	995 PRINCE FREDERICK BLVD
Second Line	:	SUITE 209
City	:	PRINCE FREDERICK
State	:	MD
Zip	:	20678-3198
Country	:	US
Telephone Number	:	410-610-6602
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. TAMERA IRELAND OLSON
Credential	:	LCSW-C
Telephone Number	:	410-610-6602

Provider Enumeration Date	:	01/20/2009
Last Update Date	:	01/03/2011

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