Provider Demographics
NPI:1134930308
Name:VINING-GONZALEZ, RICHELLE CRISTIE
Entity type:Individual
Prefix:MRS
First Name:RICHELLE
Middle Name:CRISTIE
Last Name:VINING-GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1602 SUMMIT LAKE SHORE RD NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9437
Mailing Address - Country:US
Mailing Address - Phone:360-259-8112
Mailing Address - Fax:
Practice Address - Street 1:1602 SUMMIT LAKE SHORE RD NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-9437
Practice Address - Country:US
Practice Address - Phone:360-259-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61568740101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health