Provider Demographics
NPI:1720058118
Name:ROBERTS, REGINA LEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:LEE
Last Name:ROBERTS
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:PO BOX 51946
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-1946
Mailing Address - Country:US
Mailing Address - Phone:865-281-8558
Mailing Address - Fax:888-311-9599
Practice Address - Street 1:2401 DUTCH VALLEY DR.
Practice Address - Street 2:SUITE 12
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-1731
Practice Address - Country:US
Practice Address - Phone:865-281-8558
Practice Address - Fax:888-311-9599
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW31131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3927595Medicaid
TNQ23068Medicare UPIN
TN39275951Medicare PIN