MEDICARE: JOANN BRISTOL LCSW

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
1	1041C0700X	Clinical Social Worker	17642	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679609291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANN BRISTOL LCSW

Provider Business Mailing Address
First Line	:	900 AUSTIN AVE
Second Line	:	STE. 1103
City	:	WACO
State	:	TX
Zip	:	76701-1902
Country	:	US
Telephone Number	:	254-757-1191
Fax Number	:	254-757-1150

Provider Business Practice Location Address
First Line	:	900 AUSTIN AVE
Second Line	:	STE. 1103
City	:	WACO
State	:	TX
Zip	:	76701-1902
Country	:	US
Telephone Number	:	254-757-1191
Fax Number	:	254-757-1150

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	02/07/2012

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Directions to “ JOANN BRISTOL LCSW” Practice Location

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