Provider Demographics
NPI:1730322827
Name:ELVIS, REGINA LOUISE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:LOUISE
Last Name:ELVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 REBECCA ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-7475
Mailing Address - Country:US
Mailing Address - Phone:770-378-6666
Mailing Address - Fax:
Practice Address - Street 1:271A S CULVER ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-4805
Practice Address - Country:US
Practice Address - Phone:770-676-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2009-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT004268171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor