Provider Demographics
NPI:1639513807
Name:VINES, ANGELA (LCPC, NCC, LPC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:VINES
Suffix:
Gender:F
Credentials:LCPC, NCC, LPC
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 277
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-0277
Mailing Address - Country:US
Mailing Address - Phone:757-303-8068
Mailing Address - Fax:
Practice Address - Street 1:7613 STEMHART LN
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MD
Practice Address - Zip Code:21076-2332
Practice Address - Country:US
Practice Address - Phone:757-303-8068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5695101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD103121000Medicaid