Basic Information
| Provider Information | |||||||||
| NPI: | 1558405100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REGENOVICH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | HOLLAND | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUMBACH | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | HOLLAND | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3700 FOREST DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292044010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032278118 | ||||||||
| FaxNumber: | 8032278218 | ||||||||
| Practice Location | |||||||||
| Address1: | 1924 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034342300 | ||||||||
| FaxNumber: | 8032542611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 06/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 3226 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.