Provider Demographics
NPI:1841504388
Name:MCCONLEY, REGINA LYNETTE (PHD, MPH)
Entity type:Individual
Prefix:DR
First Name:REGINA
Middle Name:LYNETTE
Last Name:MCCONLEY
Suffix:
Gender:F
Credentials:PHD, MPH
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 16310
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28408-6310
Mailing Address - Country:US
Mailing Address - Phone:910-742-9243
Mailing Address - Fax:888-746-1787
Practice Address - Street 1:5617 MAXWELL PL
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-2966
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:888-746-1787
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4021103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3849920OtherCIGNA BEHAVIORAL HEALTH
NC9179802OtherAETNA BEHAVIORAL HEALTH
NC1674YOtherBCBSNC
NC6001318Medicaid
NCP01143643OtherRR MEDICARE
NC6001318Medicaid