Provider Demographics
NPI:1962130203
Name:BRISTOW, ALEXANDRA
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:BRISTOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:303 BLUE JACKET LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-3339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6000 TURKEY LAKE RD STE 114
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-4205
Practice Address - Country:US
Practice Address - Phone:321-732-3723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-14
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician