Provider Demographics
NPI:1962537100
Name:REGAN, RANDOLF SR (CAC-AD)
Entity type:Individual
Prefix:MR
First Name:RANDOLF
Middle Name:
Last Name:REGAN
Suffix:SR
Gender:M
Credentials:CAC-AD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 N BERNICE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-3712
Mailing Address - Country:US
Mailing Address - Phone:410-967-0169
Mailing Address - Fax:410-687-6005
Practice Address - Street 1:9100 FRANKLIN SQUARE DR
Practice Address - Street 2:EATP
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3903
Practice Address - Country:US
Practice Address - Phone:410-887-6465
Practice Address - Fax:410-687-6005
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0043101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)