Provider Demographics
NPI:1104382118
Name:VINE LIFE COUNSELING
Entity Type:Organization
Organization Name:VINE LIFE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALPHONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:IVY
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC
Authorized Official - Phone:314-420-4733
Mailing Address - Street 1:2310 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1702
Mailing Address - Country:US
Mailing Address - Phone:314-420-4733
Mailing Address - Fax:
Practice Address - Street 1:2310 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1702
Practice Address - Country:US
Practice Address - Phone:314-420-4733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health