Provider Demographics
NPI:1306211438
Name:SULLIVAN, REGINA GALLOWAY
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:GALLOWAY
Last Name:SULLIVAN
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 1:1513 LINE AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4621
Mailing Address - Country:US
Mailing Address - Phone:318-670-8858
Mailing Address - Fax:318-670-8947
Practice Address - Street 1:6009 FINANCIAL PLZ STE 105
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129
Practice Address - Country:US
Practice Address - Phone:318-670-8858
Practice Address - Fax:318-670-8947
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator