Provider Demographics
NPI:1144654674
Name:WISENBAKER, REGINA KATHERINE (LCSW)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:KATHERINE
Last Name:WISENBAKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2704 N OAK ST BLDG J
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1768
Mailing Address - Country:US
Mailing Address - Phone:229-262-7333
Mailing Address - Fax:229-262-7335
Practice Address - Street 1:2704 N OAK ST BLDG J
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1768
Practice Address - Country:US
Practice Address - Phone:229-262-7333
Practice Address - Fax:229-262-7335
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-03
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0050461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGOtherUNITED HEALTH CARE
GAPENDINGMedicare PIN
GAPENDINGMedicaid
GAPENDINGOtherWELL CARE
GAPENDINGOtherTRICARE