Provider Demographics
NPI:1225528284
Name:BRISTO, BOISEY J SR (LPC)
Entity Type:Individual
Prefix:MR
First Name:BOISEY
Middle Name:J
Last Name:BRISTO
Suffix:SR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6161 AMELIA AVE.
Mailing Address - Street 2:1315
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-2141
Mailing Address - Country:US
Mailing Address - Phone:484-544-9198
Mailing Address - Fax:
Practice Address - Street 1:6161 AMELIA AVE.
Practice Address - Street 2:1315
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-2141
Practice Address - Country:US
Practice Address - Phone:484-544-9198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75700101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health