Provider Demographics
NPI:1003965740
Name:REGAN, JOHN T (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:REGAN
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MCKAIL RD
Mailing Address - Street 2:
Mailing Address - City:BRUCE
Mailing Address - State:MI
Mailing Address - Zip Code:48065-1015
Mailing Address - Country:US
Mailing Address - Phone:810-798-2389
Mailing Address - Fax:
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2445
Practice Address - Country:US
Practice Address - Phone:810-496-5640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002880103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral