Provider Demographics
NPI:1114558186
Name:BAUDENDISTEL, REGAN
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:
Last Name:BAUDENDISTEL
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:PO BOX 1446
Mailing Address - Street 2:
Mailing Address - City:ROSS
Mailing Address - State:CA
Mailing Address - Zip Code:94957-1446
Mailing Address - Country:US
Mailing Address - Phone:818-926-8401
Mailing Address - Fax:
Practice Address - Street 1:47 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:ROSS
Practice Address - State:CA
Practice Address - Zip Code:94957-9601
Practice Address - Country:US
Practice Address - Phone:818-926-8401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor