Provider Demographics
NPI:1902288046
Name:CONKLIN, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 SURREY LN
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-5682
Mailing Address - Country:US
Mailing Address - Phone:813-264-3807
Mailing Address - Fax:813-269-1372
Practice Address - Street 1:3191 CLAY MANGUM LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2501
Practice Address - Country:US
Practice Address - Phone:813-264-3807
Practice Address - Fax:813-269-1372
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4699103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical