Provider Demographics
NPI:1720135395
Name:BRISTOW, KIMBERLY N (LMHP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:LMHP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:N
Other - Last Name:BUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:124 S 24TH STREET #230
Mailing Address - Street 2:LUTHERAN FAMILY SERVICES
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68102-1226
Mailing Address - Country:US
Mailing Address - Phone:402-978-5656
Mailing Address - Fax:402-591-5075
Practice Address - Street 1:124 S 24TH STREET #230
Practice Address - Street 2:LUTHERAN FAMILY SERVICES
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102-1226
Practice Address - Country:US
Practice Address - Phone:402-978-5656
Practice Address - Fax:402-591-5075
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC2912101YM0800X
NE3919101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807126900Medicaid
ID1684791Medicare ID - Type Unspecified