Provider Demographics
NPI:1093221699
Name:WASHINGTON, BRISTOLE
Entity Type:Individual
Prefix:
First Name:BRISTOLE
Middle Name:
Last Name:WASHINGTON
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 1:2216 GINTER ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-6054
Mailing Address - Country:US
Mailing Address - Phone:804-833-0917
Mailing Address - Fax:
Practice Address - Street 1:1201 BROAD ROCK BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23249-0001
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040097491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical