Healthcare Provider Details

I. General information

NPI: 1932851367
Provider Name (Legal Business Name): TERRIS ELLIOTT REEGT, CLTM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 NORTH AVE
VILLA RICA GA
30180-1937
US

IV. Provider business mailing address

207 NORTH AVE
VILLA RICA GA
30180-1937
US

V. Phone/Fax

Practice location:
  • Phone: 770-568-8881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number23874
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number499
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number7353
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: