Provider Demographics
NPI:1538995139
Name:LICHTENBERG, REGAN
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:
Last Name:LICHTENBERG
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1054
Mailing Address - Country:US
Mailing Address - Phone:443-690-7846
Mailing Address - Fax:
Practice Address - Street 1:2211 E HIGHLAND AVE STE 140
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4867
Practice Address - Country:US
Practice Address - Phone:443-690-7846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional