Provider Demographics
NPI:1093827735
Name:BRAVO, AMY GB (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:GB
Last Name:BRAVO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3813 HERON RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3721
Mailing Address - Country:US
Mailing Address - Phone:954-849-6663
Mailing Address - Fax:
Practice Address - Street 1:1725 MAIN ST
Practice Address - Street 2:SUITE 217
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3667
Practice Address - Country:US
Practice Address - Phone:954-385-8884
Practice Address - Fax:954-385-6911
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6418103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical