Provider Demographics
NPI:1205396876
Name:BENNETT, REGINA (ASSOCIATE COUNSELOR)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:ASSOCIATE COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1478 OLD CENTRAL RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36037-6159
Mailing Address - Country:US
Mailing Address - Phone:334-382-5736
Mailing Address - Fax:334-382-0330
Practice Address - Street 1:1478 OLD CENTRAL RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:AL
Practice Address - Zip Code:36037-6159
Practice Address - Country:US
Practice Address - Phone:334-382-5736
Practice Address - Fax:334-382-0330
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2889106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst