Healthcare Provider Details

I. General information

NPI: 1083362701
Provider Name (Legal Business Name): REGINA EVIE OKOGUN SLPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10714 BALTIMORE AVENUE
BELTSVILLE MD
20705-2112
US

IV. Provider business mailing address

4105 BRIGGS CHANEY RD
BELTSVILLE MD
20705-1040
US

V. Phone/Fax

Practice location:
  • Phone: 301-802-6059
  • Fax:
Mailing address:
  • Phone: 301-802-6059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number00095L
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: