Healthcare Provider Details

I. General information

NPI: 1194007484
Provider Name (Legal Business Name): MISS REGINA RENEA BURNETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6117 MLK JR WAY THERAPEUTIC NURSERY SCHOOL
OAKLAND CA
94609-1240
US

IV. Provider business mailing address

6117 MLK JR. WAY THERAPEUTIC NURSERY SCHOOL
OAKLAND CA
94609
US

V. Phone/Fax

Practice location:
  • Phone: 510-655-4896
  • Fax: 510-658-7140
Mailing address:
  • Phone: 510-655-4896
  • Fax: 510-658-7140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: