Provider Demographics
NPI:1013244748
Name:REAGIN, DUSTIN (PSYD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:REAGIN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 NAPA VALLEJO HWY
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6293
Mailing Address - Country:US
Mailing Address - Phone:415-476-3902
Mailing Address - Fax:
Practice Address - Street 1:2100 NAPA VALLEJO HWY
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6293
Practice Address - Country:US
Practice Address - Phone:415-476-3902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA27276103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA28276Medicare UPIN