Healthcare Provider Details

I. General information

NPI: 1164992848
Provider Name (Legal Business Name): EMILY BRISTLIN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10450 185TH ST W STE 100
LAKEVILLE MN
55044-6696
US

IV. Provider business mailing address

301 MCANDREWS RD W APT 120
BURNSVILLE MN
55337-8302
US

V. Phone/Fax

Practice location:
  • Phone: 612-509-1283
  • Fax:
Mailing address:
  • Phone: 651-361-0365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-71358
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: