Provider Demographics
NPI:1568797173
Name:RAYCROFT, TATJANA ESTEP (LCSW, MAC)
Entity Type:Individual
Prefix:
First Name:TATJANA
Middle Name:ESTEP
Last Name:RAYCROFT
Suffix:
Gender:F
Credentials:LCSW, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 MAPLE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5250
Mailing Address - Country:US
Mailing Address - Phone:706-833-7601
Mailing Address - Fax:
Practice Address - Street 1:183 ACADEMIC DR BLDG 39721
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5933
Practice Address - Country:US
Practice Address - Phone:706-787-8271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0037601041C0700X
507545101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)