MEDICARE: MISS AUDREY 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	CSW.09928427	CO

General Provider Information

NPI Number	:	1912513698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS AUDREY BRISTOL LCSW

Provider Business Mailing Address
First Line	:	3903 UTICA ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80212-2246
Country	:	US
Telephone Number	:	214-986-4847
Fax Number	:

Provider Business Practice Location Address
First Line	:	1780 S BELLAIRE ST STE 485
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80222-4326
Country	:	US
Telephone Number	:	303-809-3341
Fax Number	:

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

Provider Enumeration Date	:	09/18/2020
Last Update Date	:	11/25/2024

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