Healthcare Provider Details

I. General information

NPI: 1376940098
Provider Name (Legal Business Name): ANGELICA REGINO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 MOON ST NE
ALBUQUERQUE NM
87123-2637
US

IV. Provider business mailing address

PO BOX 8951
ALBUQUERQUE NM
87198-8951
US

V. Phone/Fax

Practice location:
  • Phone: 505-573-0346
  • Fax:
Mailing address:
  • Phone: 505-948-6175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-08898
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC11614
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: