MEDICARE: MS. GINA VINES LPC

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	101Y00000X	Counselor	LPC004476	GA

General Provider Information

NPI Number	:	1922242783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GINA VINES LPC

Provider Business Mailing Address
First Line	:	665 ASHLEY LAINE WALK
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-4260
Country	:	US
Telephone Number	:	770-963-3349
Fax Number	:

Provider Business Practice Location Address
First Line	:	1810 PEACHTREE INDUSTRIAL BLVD
Second Line	:	SUITE 231
City	:	DULUTH
State	:	GA
Zip	:	30097-8180
Country	:	US
Telephone Number	:	770-963-3349
Fax Number	:

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

Provider Enumeration Date	:	04/23/2009
Last Update Date	:	04/23/2009

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