Provider Demographics
NPI:1669935276
Name:BRISTOW, MARGO D (MA, LPC, CADC, PCGC,)
Entity type:Individual
Prefix:
First Name:MARGO
Middle Name:D
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:MA, LPC, CADC, PCGC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1142 CHICAGO AVE STE 2W
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1837
Mailing Address - Country:US
Mailing Address - Phone:847-791-1651
Mailing Address - Fax:855-791-1651
Practice Address - Street 1:6912 MAIN ST STE 26
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-3447
Practice Address - Country:US
Practice Address - Phone:847-791-1651
Practice Address - Fax:855-791-1651
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.004883101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor