Provider Demographics
NPI:1023231222
Name:DEHEN, REGINA IDA (ND, LAC)
Entity type:Individual
Prefix:DR
First Name:REGINA
Middle Name:IDA
Last Name:DEHEN
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:DR
Other - First Name:REGINA
Other - Middle Name:IDA
Other - Last Name:DEHEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ND LAC
Mailing Address - Street 1:3025 SW CORBETT AVE
Mailing Address - Street 2:NCNM CLINIC
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-4858
Mailing Address - Country:US
Mailing Address - Phone:503-552-1966
Mailing Address - Fax:503-226-8133
Practice Address - Street 1:3025 SW CORBETT AVE
Practice Address - Street 2:NCNM CLINIC
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4858
Practice Address - Country:US
Practice Address - Phone:503-552-1966
Practice Address - Fax:503-226-8133
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00285171100000X
OROR ND 0879175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR138243Medicaid