Provider Demographics
NPI:1871020305
Name:LOVELESS, REGINA FAY
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:FAY
Last Name:LOVELESS
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 1:66 ARMSTRONG ROAD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728
Mailing Address - Country:US
Mailing Address - Phone:423-755-1029
Mailing Address - Fax:
Practice Address - Street 1:2403 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHROPE
Practice Address - State:GA
Practice Address - Zip Code:30742
Practice Address - Country:US
Practice Address - Phone:706-866-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2017-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA0000002729224Z00000X
GAOTA002130224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA224Z00000XMedicaid