Provider Demographics
NPI:1285602912
Name:MURRAY, REGINA MARIE (LICSW)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:MURRAY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 PRAIRIE AVE
Mailing Address - Street 2:APT. #13
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2954
Mailing Address - Country:US
Mailing Address - Phone:701-483-7133
Mailing Address - Fax:
Practice Address - Street 1:11 2ND AVE E
Practice Address - Street 2:STE. B
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-5218
Practice Address - Country:US
Practice Address - Phone:701-483-9720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND26421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19137Medicaid
ND2642OtherLICSW
ND21392OtherBCBS
NDN21392Medicare ID - Type Unspecified