MEDICARE: THERESA REGAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1508354564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA REGAN

Provider Business Mailing Address
First Line	:	1690 DAVIS DR
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-5933
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:	772-675-9100

Provider Business Practice Location Address
First Line	:	1690 DAVIS DR
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32952-5933
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:	772-675-9100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2018
Last Update Date	:	04/25/2018

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Directions to “ THERESA REGAN ” Practice Location

Language	Start Address	Practice Location

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