Provider Demographics
NPI:1912503806
Name:REGAN, SARA (RADT 1)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:REGAN
Suffix:
Gender:F
Credentials:RADT 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 MARY ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3451
Mailing Address - Country:US
Mailing Address - Phone:925-234-6001
Mailing Address - Fax:
Practice Address - Street 1:1477 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2028
Practice Address - Country:US
Practice Address - Phone:415-459-2395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1409961120324500000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility