Provider Demographics
NPI:1598085086
Name:BRISTOL, MARY F (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:F
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 1:75 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2665
Mailing Address - Country:US
Mailing Address - Phone:207-772-4110
Mailing Address - Fax:207-761-0748
Practice Address - Street 1:75 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2665
Practice Address - Country:US
Practice Address - Phone:207-772-4110
Practice Address - Fax:207-761-0748
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC11560101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health