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General NPI Number Information
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NPI Number | 1669935276
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Entity Type | Individual
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Provider Name | MARGO D BRISTOW MA, LPC, CADC, PCGC,
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Gender | Female
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Dates
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Enumeration Date | 04/10/2019
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Last Update Date | 04/10/2019
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Provider Practice Location Address
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Address Line | 6912 MAIN ST STE 26
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City | DOWNERS GROVE
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State | IL
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Zip | 60516-3447
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Country | US
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Telephone | 847-791-1651
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Fax | 855-791-1651
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Provider Business Mailing Address
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Address Line | 1142 CHICAGO AVE STE 2W
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City | OAK PARK
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State | IL
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Zip | 60302-1837
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Country | US
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Telephone | 847-791-1651
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Fax | 855-791-1651
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 178.004883
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License Number State | IL
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