Provider Demographics
NPI:1063992865
Name:KING, REGINA ELIZABETH (SLP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:ELIZABETH
Last Name:KING
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7912 DOGWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-1202
Mailing Address - Country:US
Mailing Address - Phone:916-470-2092
Mailing Address - Fax:
Practice Address - Street 1:255 LEWIS AVENUE
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:754-236-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12380235Z00000X
CA28398235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist