Provider Demographics
NPI:1710723127
Name:GRIFFIN, REGINIQUE K
Entity type:Individual
Prefix:
First Name:REGINIQUE
Middle Name:K
Last Name:GRIFFIN
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 1:1305 CONOGA ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23523-1993
Mailing Address - Country:US
Mailing Address - Phone:757-359-3204
Mailing Address - Fax:
Practice Address - Street 1:1305 CONOGA ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23523-1993
Practice Address - Country:US
Practice Address - Phone:757-359-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-04
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD1600X
VA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities