Provider Demographics
NPI:1730714288
Name:FIDAZZO, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:FIDAZZO
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 1:1401 LA BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-6614
Mailing Address - Country:US
Mailing Address - Phone:443-801-8848
Mailing Address - Fax:
Practice Address - Street 1:408 ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-4252
Practice Address - Country:US
Practice Address - Phone:410-567-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC10324101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional