Provider Demographics
NPI:1336908797
Name:BRISTOL, LARA R
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:R
Last Name:BRISTOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:R
Other - Last Name:BOSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6085 S PENNYCRESS CT
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 E NORTH ST STE A
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3720
Practice Address - Country:US
Practice Address - Phone:262-549-6123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor