Healthcare Provider Details

I. General information

NPI: 1780131797
Provider Name (Legal Business Name): STACEY REGNER MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 WILLOWHURST AVE
SAN JOSE CA
95125-5561
US

IV. Provider business mailing address

1617 WILLOWHURST AVE
SAN JOSE CA
95125-5561
US

V. Phone/Fax

Practice location:
  • Phone: 408-531-6428
  • Fax:
Mailing address:
  • Phone: 408-531-6428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number09965
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: