Provider Demographics
NPI:1740560747
Name:BATHON, REGINA ROSE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:ROSE
Last Name:BATHON
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 1:409 PANTHER DR
Mailing Address - Street 2:
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-1432
Mailing Address - Country:US
Mailing Address - Phone:618-357-5366
Mailing Address - Fax:
Practice Address - Street 1:409 PANTHER DR
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1432
Practice Address - Country:US
Practice Address - Phone:618-357-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.001368225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist