Provider Demographics
NPI:1962895664
Name:REGAN, HOLLY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:REGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12320 ASHLEY DR
Mailing Address - Street 2:STE D
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2550
Mailing Address - Country:US
Mailing Address - Phone:228-282-3655
Mailing Address - Fax:
Practice Address - Street 1:12320 ASHLEY DR
Practice Address - Street 2:STE D
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2550
Practice Address - Country:US
Practice Address - Phone:228-282-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC7870104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker