Provider Demographics
NPI:1396496568
Name:PROCTOR, CHRISTINA BALLYNCY (MED)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:BALLYNCY
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BALCONES DR STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4298
Mailing Address - Country:US
Mailing Address - Phone:832-464-6859
Mailing Address - Fax:
Practice Address - Street 1:9218 WOLCOTT PARK LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77075-3824
Practice Address - Country:US
Practice Address - Phone:713-298-4785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMSS1RKLREBU8OtherSAM ID