Basic Information
| Provider Information | |||||||||
| NPI: | 1306400056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISH | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 CLEVELAND AVE NW | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447021805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304550374 | ||||||||
| FaxNumber: | 3304536716 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 SIXTH ST SW FL 6 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447101702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308303393 | ||||||||
| FaxNumber: | 2345217091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2019 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA170369 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0346009 | 05 | OH | MEDICAID |