Provider Demographics
NPI:1245601905
Name:FACCHINO, REGINA MARIE (MA)
Entity Type:Individual
Prefix:MISS
First Name:REGINA
Middle Name:MARIE
Last Name:FACCHINO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-2249
Mailing Address - Country:US
Mailing Address - Phone:732-598-9792
Mailing Address - Fax:
Practice Address - Street 1:3349 HIGHWAY 138
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9671
Practice Address - Country:US
Practice Address - Phone:732-280-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTL-2617235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist