Provider Demographics
NPI:1285766840
Name:VINSON, ADDRIS BLANCHE (LMHC, CRC)
Entity type:Individual
Prefix:PROF
First Name:ADDRIS
Middle Name:BLANCHE
Last Name:VINSON
Suffix:
Gender:F
Credentials:LMHC, CRC
Other - Prefix:PROF
Other - First Name:KOINONIA
Other - Middle Name:DYNAMIS
Other - Last Name:INC.
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1734 HIRAM ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6105
Mailing Address - Country:US
Mailing Address - Phone:904-536-4371
Mailing Address - Fax:904-379-1760
Practice Address - Street 1:1734 HIRAM ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6105
Practice Address - Country:US
Practice Address - Phone:904-536-4371
Practice Address - Fax:904-379-1760
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 9044101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689713496Medicaid