Provider Demographics
NPI:1063012326
Name:BRAVO, SUSANA (RBT)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 RANCH ROAD 620 S STE 300
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-3900
Mailing Address - Country:US
Mailing Address - Phone:512-717-4788
Mailing Address - Fax:
Practice Address - Street 1:107 RANCH ROAD 620 S STE 300
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-3900
Practice Address - Country:US
Practice Address - Phone:512-717-4788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20-137083106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician