Provider Demographics
NPI:1760592737
Name:BANSAL, ANITA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:
Last Name:BANSAL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-0250
Mailing Address - Country:US
Mailing Address - Phone:770-667-3877
Mailing Address - Fax:770-667-3879
Practice Address - Street 1:5755 N POINT PKWY
Practice Address - Street 2:SUITE 256
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-1142
Practice Address - Country:US
Practice Address - Phone:770-667-3877
Practice Address - Fax:770-667-3879
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002662103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA685007337AMedicaid
GA685007337AMedicaid
GA68BBGHTMedicare ID - Type UnspecifiedMEDICARE