Provider Demographics
NPI:1891177705
Name:DAVIS, REGINA A (LMSW)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 GAIL HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-8116
Mailing Address - Country:US
Mailing Address - Phone:575-347-3472
Mailing Address - Fax:
Practice Address - Street 1:72 GAIL HARRIS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-8116
Practice Address - Country:US
Practice Address - Phone:575-347-3472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-26
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-092511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical