Provider Demographics
NPI:1477149763
Name:PANCAKE, REGINA KAYE
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:KAYE
Last Name:PANCAKE
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 1:136 N BURGESS HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:ELK GARDEN
Mailing Address - State:WV
Mailing Address - Zip Code:26717-9657
Mailing Address - Country:US
Mailing Address - Phone:304-788-5467
Mailing Address - Fax:304-788-6363
Practice Address - Street 1:875 S MINERAL ST
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2860
Practice Address - Country:US
Practice Address - Phone:304-788-5467
Practice Address - Fax:304-788-6363
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP942415104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker