Provider Demographics
NPI:1639342348
Name:NETTLES, REGINALD (PHD)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:
Last Name:NETTLES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6217 IRONWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4466
Mailing Address - Country:US
Mailing Address - Phone:410-290-7999
Mailing Address - Fax:443-583-2353
Practice Address - Street 1:6217 IRONWOOD WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4466
Practice Address - Country:US
Practice Address - Phone:410-290-7999
Practice Address - Fax:443-583-2353
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02642103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical