Provider Demographics
NPI:1811417884
Name:PARKER, REGINA B (LCPC)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:B
Last Name:PARKER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 CONLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3001
Mailing Address - Country:US
Mailing Address - Phone:815-895-2889
Mailing Address - Fax:
Practice Address - Street 1:12 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9637
Practice Address - Country:US
Practice Address - Phone:815-756-4875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-003001101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474579189001Medicaid