Provider Demographics
NPI:1871643056
Name:QUALLS, REGINA LOUISE (BA)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:LOUISE
Last Name:QUALLS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 HARBISON STATION CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-1687
Mailing Address - Country:US
Mailing Address - Phone:803-477-3092
Mailing Address - Fax:
Practice Address - Street 1:1800 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6827
Practice Address - Country:US
Practice Address - Phone:803-898-9825
Practice Address - Fax:803-898-2194
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health