Provider Demographics
NPI:1861554776
Name:WARD, REGINA DELICIA (EDD)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:DELICIA
Last Name:WARD
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 CHESTNUT LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4568
Mailing Address - Country:US
Mailing Address - Phone:404-456-6291
Mailing Address - Fax:
Practice Address - Street 1:3553B MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-2711
Practice Address - Country:US
Practice Address - Phone:404-289-6299
Practice Address - Fax:404-289-6298
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003980103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA834417259AMedicaid