Provider Demographics
NPI:1346709250
Name:VINE, TESSA ANNE (N/A)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:ANNE
Last Name:VINE
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 GRANITE PKWY STE 600
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6753
Mailing Address - Country:US
Mailing Address - Phone:530-379-3614
Mailing Address - Fax:
Practice Address - Street 1:250 W MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3686
Practice Address - Country:US
Practice Address - Phone:530-379-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst