Provider Demographics
NPI:1366650749
Name:WILSON, REGINA PAULETTE (PHD)
Entity Type:Individual
Prefix:MISS
First Name:REGINA
Middle Name:PAULETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109
Mailing Address - Country:US
Mailing Address - Phone:860-571-0055
Mailing Address - Fax:860-571-8466
Practice Address - Street 1:376 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109
Practice Address - Country:US
Practice Address - Phone:860-571-0055
Practice Address - Fax:860-571-8466
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002299103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist