Provider Demographics
NPI:1841069564
Name:BRISTOW, EDMUND PURCELL (MSW, LSW, LMSW)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:PURCELL
Last Name:BRISTOW
Suffix:
Gender:M
Credentials:MSW, LSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4521 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-1205
Mailing Address - Country:US
Mailing Address - Phone:504-287-5145
Mailing Address - Fax:
Practice Address - Street 1:2400 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6535
Practice Address - Country:US
Practice Address - Phone:504-214-9603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6495G1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical