Provider Demographics
NPI:1780101162
Name:LEE, REGINA A (LAC)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:A
Last Name:LEE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:ARNOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9613 E 37TH PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46235-2104
Mailing Address - Country:US
Mailing Address - Phone:317-270-0710
Mailing Address - Fax:
Practice Address - Street 1:2060 N SHADELAND AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1762
Practice Address - Country:US
Practice Address - Phone:317-270-0710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86000231A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN86000231AOtherLICENSE NUMBER