Provider Demographics
NPI:1699136747
Name:KOSTYUN, REGINA (ATC)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:KOSTYUN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:O'HARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:399 FARMINGTON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032
Mailing Address - Country:US
Mailing Address - Phone:860-284-0220
Mailing Address - Fax:
Practice Address - Street 1:399 FARMINGTON AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032
Practice Address - Country:US
Practice Address - Phone:860-284-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT559174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist