Provider Demographics
NPI:1407960719
Name:RAJCA, KRISTIN SANFORD (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:SANFORD
Last Name:RAJCA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KRISTIN
Other - Middle Name:SANFORD
Other - Last Name:GILLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1327 S 18TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362
Mailing Address - Country:US
Mailing Address - Phone:765-593-0003
Mailing Address - Fax:765-593-0032
Practice Address - Street 1:1327 S 18TH STREET
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362
Practice Address - Country:US
Practice Address - Phone:765-593-0003
Practice Address - Fax:765-593-0032
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041064A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200545040Medicaid
IN200545040Medicaid
IN945500ZMedicare ID - Type Unspecified