Basic Information
| Provider Information | |||||||||
| NPI: | 1609068667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONLEY | ||||||||
| FirstName: | REGINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 E AVENUE S | ||||||||
| Address2: | #163 | ||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935506828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6615750558 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12450 VAN NUYS BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PACOIMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913311391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188961161 | ||||||||
| FaxNumber: | 8188965069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2007 | ||||||||
| LastUpdateDate: | 08/14/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7068 | 05 | CA | MEDICAID | 7420 | 05 | CA | MEDICAID |