Healthcare Provider Details

I. General information

NPI: 1972002186
Provider Name (Legal Business Name): ANDREA L REGALADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2018
Last Update Date: 02/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S EVERGREEN AVE
ROSWELL NM
88203-1240
US

IV. Provider business mailing address

300 S EVERGREEN AVE
ROSWELL NM
88203-1240
US

V. Phone/Fax

Practice location:
  • Phone: 575-317-0767
  • Fax:
Mailing address:
  • Phone: 575-317-0767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: