Provider Demographics
NPI:1154630770
Name:BRISTOW, BRANDYLYN S (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BRANDYLYN
Middle Name:S
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2591 FOWLER ROAD
Mailing Address - Street 2:
Mailing Address - City:HERMANN
Mailing Address - State:MO
Mailing Address - Zip Code:65041
Mailing Address - Country:US
Mailing Address - Phone:573-943-9973
Mailing Address - Fax:
Practice Address - Street 1:708 EAST HIGHWAY 28
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066
Practice Address - Country:US
Practice Address - Phone:573-486-1193
Practice Address - Fax:573-486-0910
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200800009321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical