Provider Demographics
NPI:1326392325
Name:SCHLICKSUP-JOHNSON, REGINA (OTR/L)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:SCHLICKSUP-JOHNSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2407
Mailing Address - Country:US
Mailing Address - Phone:217-337-2377
Mailing Address - Fax:217-337-4609
Practice Address - Street 1:680 S. FOURTH ST.
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:217-337-2377
Practice Address - Fax:217-337-4609
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009362174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist