Provider Demographics
NPI:1316371016
Name:WAGSTER, REGINA COLINE (BSE)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:COLINE
Last Name:WAGSTER
Suffix:
Gender:F
Credentials:BSE
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:COLINE
Other - Last Name:BRANUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6263 HIGHWAY 49 SOUTH
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450
Mailing Address - Country:US
Mailing Address - Phone:870-240-0444
Mailing Address - Fax:
Practice Address - Street 1:6263 HIGHWAY 49 SOUTH
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450
Practice Address - Country:US
Practice Address - Phone:870-240-0444
Practice Address - Fax:870-240-0466
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist