Provider Demographics
NPI:1134848724
Name:BRISTOW, CAROLYN DILARA
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DILARA
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 1:130 ESSEX ST # 25A
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAMILTON
Mailing Address - State:MA
Mailing Address - Zip Code:01982-2325
Mailing Address - Country:US
Mailing Address - Phone:843-814-2056
Mailing Address - Fax:
Practice Address - Street 1:110 BOSTON ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-1402
Practice Address - Country:US
Practice Address - Phone:978-744-7905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health