Provider Demographics
NPI:1013584010
Name:BRAVO CARMONA, BETZABET
Entity Type:Individual
Prefix:
First Name:BETZABET
Middle Name:
Last Name:BRAVO CARMONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 WILLIAMS TRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-4514
Mailing Address - Country:US
Mailing Address - Phone:281-865-3063
Mailing Address - Fax:
Practice Address - Street 1:2205 WILLIAMS TRACE BLVD
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4514
Practice Address - Country:US
Practice Address - Phone:281-865-3063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBACB67446106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician