Provider Demographics
NPI:1134577315
Name:PETILL, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:PETILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:PETILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAP
Mailing Address - Street 1:16244 S MILITARY TRL STE 110
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-6505
Mailing Address - Country:US
Mailing Address - Phone:561-865-2550
Mailing Address - Fax:561-865-2558
Practice Address - Street 1:16244 S MILITARY TRL STE 110
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6505
Practice Address - Country:US
Practice Address - Phone:561-865-2550
Practice Address - Fax:561-865-2558
Is Sole Proprietor?:No
Enumeration Date:2016-05-30
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5439101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)