Provider Demographics
NPI:1912942004
Name:SWICKARD, REGINA MARIE (C PED)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:SWICKARD
Suffix:
Gender:F
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 WATERVLIET AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-2544
Mailing Address - Country:US
Mailing Address - Phone:937-256-3668
Mailing Address - Fax:937-256-1650
Practice Address - Street 1:617 WATERVLIET AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-2544
Practice Address - Country:US
Practice Address - Phone:937-256-3668
Practice Address - Fax:937-256-1650
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPED-0051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5727860001Medicare NSC