Provider Demographics
NPI:1033365994
Name:REGALADO, ROBERTA RENEE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:RENEE
Last Name:REGALADO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7100
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88355-7100
Mailing Address - Country:US
Mailing Address - Phone:575-257-5820
Mailing Address - Fax:575-257-9560
Practice Address - Street 1:628 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6204
Practice Address - Country:US
Practice Address - Phone:575-257-5820
Practice Address - Fax:575-257-9560
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-12
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3551225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist