Provider Demographics
NPI:1699959270
Name:NOWATZKE, REGINA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:NOWATZKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:M
Other - Last Name:VANREES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5239 NE HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:YACHATS
Mailing Address - State:OR
Mailing Address - Zip Code:97498-9009
Mailing Address - Country:US
Mailing Address - Phone:541-265-4179
Mailing Address - Fax:541-574-6252
Practice Address - Street 1:5239 NE HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:YACHATS
Practice Address - State:OR
Practice Address - Zip Code:97498-9009
Practice Address - Country:US
Practice Address - Phone:541-265-4179
Practice Address - Fax:541-574-6252
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL7531104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200537330AMedicaid
OR500735581Medicaid