Provider Demographics
NPI:1215323274
Name:D'VINE INTERVENTION COUNSELING CENTER
Entity type:Organization
Organization Name:D'VINE INTERVENTION COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHRISTIAN THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LETESHA
Authorized Official - Middle Name:RENEE'
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:252-673-3196
Mailing Address - Street 1:116 PIEDMONT COURT
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870
Mailing Address - Country:US
Mailing Address - Phone:252-673-3196
Mailing Address - Fax:
Practice Address - Street 1:2424 OAK STREET
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:27870
Practice Address - Country:US
Practice Address - Phone:252-673-3196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005691251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health