Provider Demographics
NPI:1376393884
Name:AMMONS, REGINA GAYLE (LPC)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:GAYLE
Last Name:AMMONS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7317 BRIDLE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-8736
Mailing Address - Country:US
Mailing Address - Phone:662-772-6697
Mailing Address - Fax:
Practice Address - Street 1:7317 BRIDLE LN
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-8736
Practice Address - Country:US
Practice Address - Phone:662-772-6697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3098101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health