Provider Demographics
NPI:1972827970
Name:FORMICA, REGINA L (PT)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:L
Last Name:FORMICA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 S 11TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:QUAKERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18951-1414
Mailing Address - Country:US
Mailing Address - Phone:215-538-1999
Mailing Address - Fax:
Practice Address - Street 1:624 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2964
Practice Address - Country:US
Practice Address - Phone:215-538-1999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-006061-L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist