Healthcare Provider Details

I. General information

NPI: 1932303062
Provider Name (Legal Business Name): JAMES EDWIN BRISTOL III M.A., M.DIV., J.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

317 PASEO DE PERALTA
SANTA FE NM
87501-1860
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-5540
  • Fax:
Mailing address:
  • Phone: 505-986-5423
  • Fax: 505-855-9585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05175
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: