Provider Demographics
NPI:1538562590
Name:BANCROFT, CHRISTINA ANNE (PHD)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ANNE
Last Name:BANCROFT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:ANNE
Other - Last Name:TALMADGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 15TH ST # OR-6000
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:706-721-3813
Mailing Address - Fax:706-721-9286
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-3341
Practice Address - Country:US
Practice Address - Phone:706-721-7874
Practice Address - Fax:706-721-1793
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11104101YM0800X
NCA11104101YP2500X
GAPSY004515103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional