Basic Information
| Provider Information | |||||||||
| NPI: | 1619360914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEWELL | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PCCI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 W LA VETA AVE | ||||||||
| Address2: | UNIT O-18 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684401 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 N PACIFIC COAST HWY | ||||||||
| Address2: | STE. 200A | ||||||||
| City: | REDONDO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902772162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103161610 | ||||||||
| FaxNumber: | 3103164209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2015 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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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 | 1766 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.