Provider Demographics
NPI:1376076455
Name:BRISTOW, REBECCA (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E 5TH ST
Mailing Address - Street 2:APT 2822
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-4157
Mailing Address - Country:US
Mailing Address - Phone:512-925-3381
Mailing Address - Fax:
Practice Address - Street 1:555 E 5TH ST
Practice Address - Street 2:APT 2822
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-4157
Practice Address - Country:US
Practice Address - Phone:512-925-3381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110842235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist