Provider Demographics
NPI:1245672997
Name:SIEZ, REGINA RAE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:RAE
Last Name:SIEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35408 FOXWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-2911
Mailing Address - Country:US
Mailing Address - Phone:951-757-1528
Mailing Address - Fax:
Practice Address - Street 1:35408 FOXWOOD CT
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-2911
Practice Address - Country:US
Practice Address - Phone:951-757-1528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS256601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAPPLIED FORMedicaid