Provider Demographics
NPI:1053443812
Name:BRISTOW, ALICE LYNN
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:LYNN
Last Name:BRISTOW
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 1:707 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-2506
Mailing Address - Country:US
Mailing Address - Phone:209-525-6041
Mailing Address - Fax:209-525-6034
Practice Address - Street 1:707 14TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-2506
Practice Address - Country:US
Practice Address - Phone:209-525-6041
Practice Address - Fax:209-525-6034
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 230791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical