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General NPI Number Information
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NPI Number | 1922420579
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Entity Type | Organization
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Legal Business Name | REGINA KATHERINE WISENBAKER
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Dates
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Enumeration Date | 01/16/2014
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Last Update Date | 04/09/2014
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Provider Practice Location Address
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Address Line | 415 COWART AVE STE B
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City | VALDOSTA
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State | GA
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Zip | 31602-2651
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Country | US
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Telephone | 229-630-6587
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Fax | 229-257-0757
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Provider Business Mailing Address
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Address Line | 415 COWART AVE STE B
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City | VALDOSTA
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State | GA
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Zip | 31602-2651
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Country | US
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Telephone | 229-630-6587
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. REGINA KATHERINE WISENBAKER
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Credential | LCSW
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Telephone | 229-630-6587
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | CSW005046
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License Number State | GA
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