Provider Demographics
NPI:1619050945
Name:HINES, VIRGINIA BRADLEY (LMHC AND PA)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:BRADLEY
Last Name:HINES
Suffix:
Gender:F
Credentials:LMHC AND PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-0393
Mailing Address - Country:US
Mailing Address - Phone:978-371-8255
Mailing Address - Fax:978-371-8255
Practice Address - Street 1:86 FAIRHAVEN RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3522
Practice Address - Country:US
Practice Address - Phone:978-371-8255
Practice Address - Fax:978-371-8255
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA573363AM0700X
MA6449101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical