Provider Demographics
NPI:1174030704
Name:BRISTOW, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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 1:5949 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086-9523
Mailing Address - Country:US
Mailing Address - Phone:716-684-1495
Mailing Address - Fax:
Practice Address - Street 1:5949 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14086-9523
Practice Address - Country:US
Practice Address - Phone:716-684-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015920225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist