Provider Demographics
NPI:1821122771
Name:ARVIN, REGINA SUSAN (MS-SLP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:SUSAN
Last Name:ARVIN
Suffix:
Gender:F
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 SOMERSET RDG NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5716
Mailing Address - Country:US
Mailing Address - Phone:770-427-8117
Mailing Address - Fax:770-427-8117
Practice Address - Street 1:3720 SOMERSET RDG NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5716
Practice Address - Country:US
Practice Address - Phone:770-427-8117
Practice Address - Fax:770-427-8117
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000687178EMedicaid