Provider Demographics
NPI:1316114762
Name:BLAINE, REGINA ROSCHELE
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:ROSCHELE
Last Name:BLAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 ORANGE AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-1777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4211 AVALON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-5622
Practice Address - Country:US
Practice Address - Phone:323-432-5185
Practice Address - Fax:323-432-5086
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29689101YM0800X
CA700181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical