Provider Demographics
NPI:1801451281
Name:DAVIS, REGINA SULLIVAN (AA, CPSS, CPRC)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:SULLIVAN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:AA, CPSS, CPRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3937 SUNSET BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4302
Mailing Address - Country:US
Mailing Address - Phone:803-567-3059
Mailing Address - Fax:800-290-8136
Practice Address - Street 1:3937 SUNSET BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4302
Practice Address - Country:US
Practice Address - Phone:803-567-3059
Practice Address - Fax:800-290-8136
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2736403175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist