Provider Demographics
NPI:1417164872
Name:BRISTOL, JUDITH MARIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:MARIA
Last Name:BRISTOL
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 1:4303 WESTMORELAND ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11363-1943
Mailing Address - Country:US
Mailing Address - Phone:718-224-8816
Mailing Address - Fax:
Practice Address - Street 1:11045 71ST RD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4960
Practice Address - Country:US
Practice Address - Phone:718-224-8816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO150371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY64106Medicare ID - Type Unspecified