Provider Demographics
NPI:1508487489
Name:WINE, DEBRA LYNN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:LYNN
Last Name:WINE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:DEBRA
Other - Middle Name:LYNN
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:820 EDISON BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2116
Mailing Address - Country:US
Mailing Address - Phone:810-650-6205
Mailing Address - Fax:
Practice Address - Street 1:309 HURON AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3869
Practice Address - Country:US
Practice Address - Phone:810-689-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-01
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010197671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical