Provider Demographics
NPI:1063650273
Name:BRAZA, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:BRAZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 S LEWIS RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-8520
Mailing Address - Country:US
Mailing Address - Phone:805-383-3669
Mailing Address - Fax:
Practice Address - Street 1:1510 HELM DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93035-3201
Practice Address - Country:US
Practice Address - Phone:805-382-1268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA174400000XOtherOTHER