Provider Demographics
NPI:1740658624
Name:LOUIS, REGINALD
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:LOUIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 POPLAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-2462
Mailing Address - Country:US
Mailing Address - Phone:904-860-8628
Mailing Address - Fax:
Practice Address - Street 1:3434 POPLAR RIDGE DR
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-2462
Practice Address - Country:US
Practice Address - Phone:904-860-8628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009649101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional