Provider Demographics
NPI:1396910022
Name:HOLLIBUSH, REGINA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:
Last Name:HOLLIBUSH
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 1:12099 LINDSTROM LN
Mailing Address - Street 2:
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-9543
Mailing Address - Country:US
Mailing Address - Phone:651-243-8967
Mailing Address - Fax:
Practice Address - Street 1:12099 LINDSTROM LN
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045-9543
Practice Address - Country:US
Practice Address - Phone:651-257-8896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN189101041C0700X
WI6925-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43588300Medicaid