Healthcare Provider Details

I. General information

NPI: 1538391123
Provider Name (Legal Business Name): CONNIE REGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 MAMIE ST
HATTIESBURG MS
39402-1735
US

IV. Provider business mailing address

141 WILLOW BROOK DR
HATTIESBURG MS
39402-1488
US

V. Phone/Fax

Practice location:
  • Phone: 601-705-1901
  • Fax:
Mailing address:
  • Phone: 601-705-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberC1017
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC1017
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: