Provider Demographics
NPI:1003787417
Name:CLARK, REGINA DIANE
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:DIANE
Last Name:CLARK
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 1:68 CROMWELL PL APT 1
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-1761
Mailing Address - Country:US
Mailing Address - Phone:757-944-5428
Mailing Address - Fax:
Practice Address - Street 1:68 CROMWELL PL APT 1
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-1761
Practice Address - Country:US
Practice Address - Phone:757-944-5428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-17
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator