Provider Demographics
NPI:1508953902
Name:ARCHER, REGINA MARIE
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:MARIE
Last Name:ARCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:ML
Other - Last Name:ERIKSSON ARCHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFC
Mailing Address - Street 1:829 ESTANCIA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2905
Mailing Address - Country:US
Mailing Address - Phone:415-499-6751
Mailing Address - Fax:415-499-3080
Practice Address - Street 1:161 MITCHELL BLVD
Practice Address - Street 2:101
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2068
Practice Address - Country:US
Practice Address - Phone:415-499-6751
Practice Address - Fax:415-499-3080
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33763106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist