Provider Demographics
NPI:1407545882
Name:AUSTIN-FORD, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:AUSTIN-FORD
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 1:3872 AVA WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-2204
Mailing Address - Country:US
Mailing Address - Phone:757-802-2149
Mailing Address - Fax:
Practice Address - Street 1:3872 AVA WAY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-2204
Practice Address - Country:US
Practice Address - Phone:757-802-2149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA6503251C00000X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No305R00000XManaged Care OrganizationsPreferred Provider Organization