Provider Demographics
NPI:1225722846
Name:GEORGIA, REGINALD (MSED, LMHCA, NCC)
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:
Last Name:GEORGIA
Suffix:
Gender:M
Credentials:MSED, LMHCA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7951 CALUMET AVE # 1042
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1215
Mailing Address - Country:US
Mailing Address - Phone:708-967-3273
Mailing Address - Fax:
Practice Address - Street 1:2751 40TH ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2731
Practice Address - Country:US
Practice Address - Phone:708-682-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001980A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor