Provider Demographics
NPI:1447204680
Name:VINE, ROBERTA ANN (LPCC)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:ANN
Last Name:VINE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 BURBERRY ST NW
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-9517
Mailing Address - Country:US
Mailing Address - Phone:330-494-6703
Mailing Address - Fax:
Practice Address - Street 1:101 CLEVELAND AVE NW
Practice Address - Street 2:SUITE 300
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-1700
Practice Address - Country:US
Practice Address - Phone:330-454-7066
Practice Address - Fax:330-454-9427
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0000366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional