Provider Demographics
NPI:1447577747
Name:MATTHEWS, REGINA
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:
Last Name:MATTHEWS
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 1:6335 WATERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-4882
Mailing Address - Country:US
Mailing Address - Phone:317-641-4835
Mailing Address - Fax:317-663-2963
Practice Address - Street 1:6335 WATERSTONE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-4882
Practice Address - Country:US
Practice Address - Phone:317-641-4835
Practice Address - Fax:317-663-2963
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20901107225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist