Provider Demographics
NPI:1457437915
Name:BRISTOW, BOYD A (LPC-MH,QMHP,LMFT,MA)
Entity Type:Individual
Prefix:
First Name:BOYD
Middle Name:A
Last Name:BRISTOW
Suffix:
Gender:M
Credentials:LPC-MH,QMHP,LMFT,MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 N DULUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-2714
Mailing Address - Country:US
Mailing Address - Phone:605-988-3775
Mailing Address - Fax:605-988-3747
Practice Address - Street 1:523 N DULUTH AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-2714
Practice Address - Country:US
Practice Address - Phone:605-988-3775
Practice Address - Fax:605-988-3747
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH 2052101YM0800X
SDLMFT 1170106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4998932OtherBCBS
SD6575340Medicaid