Provider Demographics
NPI:1528673944
Name:CLYBURNE, REGINA S (APC)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:S
Last Name:CLYBURNE
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:S
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:126 ENTERPRISE PATH STE 205
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2654
Mailing Address - Country:US
Mailing Address - Phone:678-408-1513
Mailing Address - Fax:
Practice Address - Street 1:126 ENTERPRISE PATH STE 205
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2654
Practice Address - Country:US
Practice Address - Phone:678-408-1513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007542101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health