Provider Demographics
NPI:1275065328
Name:VINES, LAUREN MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
Last Name:VINES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MICHELLE
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11764 ELKO LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-4755
Mailing Address - Country:US
Mailing Address - Phone:682-220-8739
Mailing Address - Fax:
Practice Address - Street 1:11764 ELKO LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-4755
Practice Address - Country:US
Practice Address - Phone:682-220-8739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX679961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health