Provider Demographics
NPI:1922091750
Name:BRISTOL, RICHARD THOMAS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:THOMAS
Last Name:BRISTOL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PALMER RD
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1842
Mailing Address - Country:US
Mailing Address - Phone:617-964-4605
Mailing Address - Fax:
Practice Address - Street 1:129 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-6497
Practice Address - Country:US
Practice Address - Phone:617-964-4605
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4205103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04163Medicare ID - Type UnspecifiedBLUE CROSS ID