Provider Demographics
NPI:1265803548
Name:HARTLEY, REGINA (RAC)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:RAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 JORDAN ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4615
Mailing Address - Country:US
Mailing Address - Phone:318-364-7673
Mailing Address - Fax:
Practice Address - Street 1:416 WILDOAK DR
Practice Address - Street 2:
Practice Address - City:HAUGHTON
Practice Address - State:LA
Practice Address - Zip Code:71037-7927
Practice Address - Country:US
Practice Address - Phone:318-364-7673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1510101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)