Provider Demographics
NPI:1992150841
Name:VINES, KEESHA (LGPC)
Entity type:Individual
Prefix:
First Name:KEESHA
Middle Name:
Last Name:VINES
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6716 FLYING SQUIRREL CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4332
Mailing Address - Country:US
Mailing Address - Phone:214-636-3761
Mailing Address - Fax:
Practice Address - Street 1:30007 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE HALL
Practice Address - State:MD
Practice Address - Zip Code:20622-3101
Practice Address - Country:US
Practice Address - Phone:301-997-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP6116101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor