Provider Demographics
NPI:1699864777
Name:VINES, DARA LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:DARA
Middle Name:LYNN
Last Name:VINES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5935 S GARTH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1513
Mailing Address - Country:US
Mailing Address - Phone:310-216-0505
Mailing Address - Fax:310-216-0505
Practice Address - Street 1:2566 OVERLAND AVE
Practice Address - Street 2:SUITE 500A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-3366
Practice Address - Country:US
Practice Address - Phone:310-216-0505
Practice Address - Fax:310-216-0505
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11577103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical