Provider Demographics
NPI:1235301656
Name:BROWN, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30700 TELEGRAPH RD STE 3450
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4527
Mailing Address - Country:US
Mailing Address - Phone:248-987-4721
Mailing Address - Fax:248-715-6804
Practice Address - Street 1:30700 TELEGRAPH RD STE 3450
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4527
Practice Address - Country:US
Practice Address - Phone:248-987-4721
Practice Address - Fax:248-715-6804
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361000599103TC0700X, 103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI16658Medicaid