Healthcare Provider Details

I. General information

NPI: 1083943435
Provider Name (Legal Business Name): REGINA WAYNE LPC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NEW HARWINTON RD
TORRINGTON CT
06790-5932
US

IV. Provider business mailing address

913 NEW HARWINTON RD
TORRINGTON CT
06790-5932
US

V. Phone/Fax

Practice location:
  • Phone: 860-309-7262
  • Fax: 860-482-0704
Mailing address:
  • Phone: 860-309-7262
  • Fax: 860-482-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000360
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number00935
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: