Provider Demographics
NPI:1831319722
Name:MCLEAN, REGINA MARIE (MS PT)
Entity type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:MARIE
Last Name:MCLEAN
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MILDRED CT
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1621
Mailing Address - Country:US
Mailing Address - Phone:631-361-3609
Mailing Address - Fax:
Practice Address - Street 1:269 EAST MAIN MAIN STREET
Practice Address - Street 2:SUITE E3
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-724-3150
Practice Address - Fax:631-724-3117
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013169174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013169OtherPHYCIAL THERAPY LICENSE #