Provider Demographics
NPI:1912382482
Name:RADZICKI, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:RADZICKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 AVONWOOD RD APT 106
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 MACKENAN DR
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-7903
Practice Address - Country:US
Practice Address - Phone:919-371-2848
Practice Address - Fax:919-467-6777
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1149532103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst