Provider Demographics
NPI:1922242783
Name:VINES, GINA (LPC)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:
Last Name:VINES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 ASHLEY LAINE WALK
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-4260
Mailing Address - Country:US
Mailing Address - Phone:770-963-3349
Mailing Address - Fax:
Practice Address - Street 1:1810 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 231
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8180
Practice Address - Country:US
Practice Address - Phone:770-963-3349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004476101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor