Healthcare Provider Details

I. General information

NPI: 1699380055
Provider Name (Legal Business Name): CAROLINE REGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2020
Last Update Date: 09/12/2020
Certification Date: 09/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 MCCALLISTER RD
GERALD MO
63037-3104
US

IV. Provider business mailing address

5100 MCCALLISTER RD
GERALD MO
63037-3104
US

V. Phone/Fax

Practice location:
  • Phone: 573-406-3541
  • Fax:
Mailing address:
  • Phone: 573-406-3541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2000174412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: