Provider Demographics
NPI:1598159154
Name:CANTRELL-KINZFOGL, REGINA NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:NICOLE
Last Name:CANTRELL-KINZFOGL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:NICOLE
Other - Last Name:CANTRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3800 COOLIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-3399
Mailing Address - Country:US
Mailing Address - Phone:510-846-9966
Mailing Address - Fax:510-485-5351
Practice Address - Street 1:3800 COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-3399
Practice Address - Country:US
Practice Address - Phone:510-846-9966
Practice Address - Fax:510-485-5351
Is Sole Proprietor?:No
Enumeration Date:2015-03-22
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA805141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker