Provider Demographics
NPI:1376136937
Name:BACON, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:BACON
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 1:45 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SHILLINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19607-2713
Mailing Address - Country:US
Mailing Address - Phone:610-568-0121
Mailing Address - Fax:
Practice Address - Street 1:2208 QUARRY DR STE 200
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19609-1158
Practice Address - Country:US
Practice Address - Phone:610-563-2052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009769101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional