Healthcare Provider Details

I. General information

NPI: 1144119884
Provider Name (Legal Business Name): REGINA RAYBOURN MS, LIAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2025
Last Update Date: 06/30/2025
Certification Date: 06/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 S ALMA SCHOOL RD STE 312
MESA AZ
85210-3039
US

IV. Provider business mailing address

4114 W WOODRIDGE DR
GLENDALE AZ
85308-4016
US

V. Phone/Fax

Practice location:
  • Phone: 480-687-2334
  • Fax:
Mailing address:
  • Phone: 606-465-3166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number155380
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: