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NPI Code Detail

MEDICARE: MR. BOISEY J BRISTO SR. LPC

MEDICARE: MR. BOISEY J BRISTO SR. LPC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor75700TX
2101YP2500XProfessional Counselor75700TX

General Provider Information

NPI Number : 1225528284
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BOISEY J BRISTO SR. LPC
Provider Business Mailing Address
First Line : 6161 AMELIA AVE.
Second Line : 1315
City : FORT WORTH
State : TX
Zip : 76123-2141
Country : US
Telephone Number : 484-544-9198
Fax Number :
Provider Business Practice Location Address
First Line : 6161 AMELIA AVE.
Second Line : 1315
City : FORT WORTH
State : TX
Zip : 76123-2141
Country : US
Telephone Number : 484-544-9198
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/15/2018
Last Update Date : 08/18/2023

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