Provider Demographics
NPI:1376080200
Name:SICKLES, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:SICKLES
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 1:2545 NE COACHMAN RD APT 150
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-1810
Mailing Address - Country:US
Mailing Address - Phone:727-687-9261
Mailing Address - Fax:
Practice Address - Street 1:2545 NE COACHMAN RD APT 150
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-1810
Practice Address - Country:US
Practice Address - Phone:727-687-9261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB268792106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst