Provider Demographics
NPI:1053346502
Name:WALL, REGINA (MSW LCSW BCD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:MSW LCSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 POINT CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2861
Mailing Address - Country:US
Mailing Address - Phone:609-434-1418
Mailing Address - Fax:
Practice Address - Street 1:100 STRAUBE CENTER BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-1447
Practice Address - Country:US
Practice Address - Phone:609-298-9144
Practice Address - Fax:609-298-9288
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSC014361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical