Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 13907 | IL |
N | 1041C0700X | Clinical Social Worker | IL |
NPI | 1518974302 |
---|---|
Provider Name | Ms. Cheryl Denise Bristor |
First Address | Alsip, IL 60803-7782 |
Second Address | Alsip, IL 60803-1082 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2006 |
Last Update Date | 08/07/2007 |