Provider Demographics
NPI:1043635097
Name:BRAVO, JOSHUA (LCSW)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1078
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-1078
Mailing Address - Country:US
Mailing Address - Phone:801-573-6323
Mailing Address - Fax:
Practice Address - Street 1:1380 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-5336
Practice Address - Country:US
Practice Address - Phone:801-573-6323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-27
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7113178-3501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health