Provider Demographics
NPI:1366411290
Name:VINES, FREDDIE DEAN
Entity type:Individual
Prefix:
First Name:FREDDIE
Middle Name:DEAN
Last Name:VINES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8589 E CREEK LN
Mailing Address - Street 2:
Mailing Address - City:HAYES
Mailing Address - State:VA
Mailing Address - Zip Code:23072-3748
Mailing Address - Country:US
Mailing Address - Phone:757-873-2307
Mailing Address - Fax:
Practice Address - Street 1:703 THIMBLE SHOALS BLVD
Practice Address - Street 2:A-3
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2576
Practice Address - Country:US
Practice Address - Phone:757-873-2307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040020781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical