Provider Demographics
NPI:1659980274
Name:BRISTOW, LINDSEY JORDAN
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:JORDAN
Last Name:BRISTOW
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:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:COALVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84017-0688
Mailing Address - Country:US
Mailing Address - Phone:435-919-7234
Mailing Address - Fax:
Practice Address - Street 1:327 W GORDON AVE
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2377
Practice Address - Country:US
Practice Address - Phone:385-399-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician