Provider Demographics
NPI:1831912955
Name:VINES, KERRI PATRICIA (CIT)
Entity type:Individual
Prefix:MS
First Name:KERRI
Middle Name:PATRICIA
Last Name:VINES
Suffix:
Gender:F
Credentials:CIT
Other - Prefix:MS
Other - First Name:KERRI
Other - Middle Name:SMALL
Other - Last Name:VINES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CIT
Mailing Address - Street 1:2651 BARRON RD LOT 412
Mailing Address - Street 2:
Mailing Address - City:KEITHVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71047-7353
Mailing Address - Country:US
Mailing Address - Phone:318-510-6363
Mailing Address - Fax:
Practice Address - Street 1:6240 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-8413
Practice Address - Country:US
Practice Address - Phone:318-562-6320
Practice Address - Fax:318-855-8779
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5857101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)