Provider Demographics
NPI:1255576765
Name:VINES, DESHRA MICHELLE
Entity type:Individual
Prefix:MRS
First Name:DESHRA
Middle Name:MICHELLE
Last Name:VINES
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 1:714 LIPPINCOTT BLVD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5818
Mailing Address - Country:US
Mailing Address - Phone:810-233-6696
Mailing Address - Fax:810-233-6696
Practice Address - Street 1:714 LIPPINCOTT BLVD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5818
Practice Address - Country:US
Practice Address - Phone:810-233-6696
Practice Address - Fax:810-233-6696
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS250263327320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9099470OtherDHS PROVIDER ID NUMBER