Provider Demographics
NPI:1952654311
Name:HUBBARD, REGENIA (LCSW-A)
Entity Type:Individual
Prefix:
First Name:REGENIA
Middle Name:
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-4922
Mailing Address - Country:US
Mailing Address - Phone:919-488-0015
Mailing Address - Fax:919-277-0066
Practice Address - Street 1:11130 CAPITAL BLVD
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-4513
Practice Address - Country:US
Practice Address - Phone:919-488-4094
Practice Address - Fax:919-488-4096
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0074731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCCOO9113OtherLICENSE