Healthcare Provider Details

I. General information

NPI: 1538562590
Provider Name (Legal Business Name): CHRISTINA ANNE BANCROFT PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA ANNE TALMADGE

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-3341
US

IV. Provider business mailing address

1120 15TH ST # OR-6000
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-7874
  • Fax: 706-721-1793
Mailing address:
  • Phone: 706-721-3813
  • Fax: 706-721-9286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11104
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA11104
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPSY004515
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: