Provider Demographics
NPI:1144119884
Name:RAYBOURN, REGINA (MS, LIAC)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:
Last Name:RAYBOURN
Suffix:
Gender:F
Credentials:MS, LIAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 W WOODRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4016
Mailing Address - Country:US
Mailing Address - Phone:606-465-3166
Mailing Address - Fax:
Practice Address - Street 1:1921 S ALMA SCHOOL RD STE 312
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3039
Practice Address - Country:US
Practice Address - Phone:480-687-2334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AZ155380101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health