Provider Demographics
NPI:1922446905
Name:BRISTOL, DANIEL R (MA)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:R
Last Name:BRISTOL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 E CARO RD
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-9319
Mailing Address - Country:US
Mailing Address - Phone:989-673-2500
Mailing Address - Fax:
Practice Address - Street 1:1655 E CARO RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-9319
Practice Address - Country:US
Practice Address - Phone:989-673-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301003981103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical