Provider Demographics
NPI:1962816967
Name:BRISTOW, RONALD RAY (LCPC, MS)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:RAY
Last Name:BRISTOW
Suffix:
Gender:M
Credentials:LCPC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 E BELVIDERE RD
Mailing Address - Street 2:SUITE 319
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2568
Mailing Address - Country:US
Mailing Address - Phone:847-924-0261
Mailing Address - Fax:
Practice Address - Street 1:888 E BELVIDERE RD
Practice Address - Street 2:SUITE 319
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2568
Practice Address - Country:US
Practice Address - Phone:847-924-0261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional