Provider Demographics
NPI:1467182030
Name:BRISTOL, LETICIA DIANA
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:DIANA
Last Name:BRISTOL
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 1:4802 FREDERICK AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-4040
Mailing Address - Country:US
Mailing Address - Phone:141-049-9555
Mailing Address - Fax:
Practice Address - Street 1:12200 PLUM ORCHARD DR STE 120A
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7843
Practice Address - Country:US
Practice Address - Phone:301-850-1148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician