Provider Demographics
NPI:1801357215
Name:PREVOSTO, REGINA (LMT)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:PREVOSTO
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 1:1388 PROGRESS WAY
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-6463
Mailing Address - Country:US
Mailing Address - Phone:432-481-8544
Mailing Address - Fax:
Practice Address - Street 1:1388 PROGRESS WAY
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6463
Practice Address - Country:US
Practice Address - Phone:303-931-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM05841225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist