Provider Demographics
NPI:1669957734
Name:ERTZ, REGINA SIOUX (PHD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:SIOUX
Last Name:ERTZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 GORDON COOPER DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-9007
Mailing Address - Country:US
Mailing Address - Phone:405-214-5101
Mailing Address - Fax:405-878-5846
Practice Address - Street 1:2307 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9007
Practice Address - Country:US
Practice Address - Phone:405-214-5101
Practice Address - Fax:405-878-5846
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1319103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical