Provider Demographics
NPI:1124232012
Name:BRAVO, RALPH ANTHONY
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:ANTHONY
Last Name:BRAVO
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 1:5380 FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509
Mailing Address - Country:US
Mailing Address - Phone:951-304-5776
Mailing Address - Fax:951-304-5777
Practice Address - Street 1:1777 ATLANTA AVE
Practice Address - Street 2:SUITE G-1
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7417
Practice Address - Country:US
Practice Address - Phone:951-304-5776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)