Provider Demographics
NPI:1972143006
Name:MICELI, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:MICELI
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 1:4679 MONTMARTRE PARK CT
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-5952
Mailing Address - Country:US
Mailing Address - Phone:219-669-7696
Mailing Address - Fax:
Practice Address - Street 1:197 E HAMILTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0261
Practice Address - Country:US
Practice Address - Phone:408-679-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC5518101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health