Healthcare Provider Details

I. General information

NPI: 1912383621
Provider Name (Legal Business Name): MICHAEL REGAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 01/20/2024
Certification Date: 01/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 BUCK HILL RD
WURTSBORO NY
12790-5227
US

IV. Provider business mailing address

15 SULLIVAN AVE
PORT JERVIS NY
12771-1616
US

V. Phone/Fax

Practice location:
  • Phone: 570-906-0168
  • Fax:
Mailing address:
  • Phone: 570-906-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089196
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: