Provider Demographics
NPI:1487704649
Name:BACON, CHRISTINA G (MS, LPP)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:G
Last Name:BACON
Suffix:
Gender:F
Credentials:MS, LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 OAK BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-9581
Mailing Address - Country:US
Mailing Address - Phone:859-302-1768
Mailing Address - Fax:
Practice Address - Street 1:292 GLADES RD STE 8
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403
Practice Address - Country:US
Practice Address - Phone:859-985-7862
Practice Address - Fax:859-972-0616
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY137685103T00000X
KY247601103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100610370Medicaid
KY3383Medicare ID - Type UnspecifiedMEDICARE