Provider Demographics
NPI:1598434821
Name:BLAKE, REGALIA LYN (RADT)
Entity Type:Individual
Prefix:MS
First Name:REGALIA
Middle Name:LYN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2391 WARREN RD
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582
Mailing Address - Country:US
Mailing Address - Phone:951-390-2267
Mailing Address - Fax:951-390-2267
Practice Address - Street 1:2391 WARREN RD
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92582
Practice Address - Country:US
Practice Address - Phone:951-390-2267
Practice Address - Fax:951-390-2267
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1441980821101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)