Provider Demographics
NPI:1043054075
Name:REGENERIZE PSYCHIATRY PLLC
Entity type:Organization
Organization Name:REGENERIZE PSYCHIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-899-5997
Mailing Address - Street 1:605 S OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1154
Mailing Address - Country:US
Mailing Address - Phone:208-606-0620
Mailing Address - Fax:
Practice Address - Street 1:605 S OLIVE AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1154
Practice Address - Country:US
Practice Address - Phone:209-677-7747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-24
Last Update Date:2024-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)