Provider Demographics
NPI:1164668067
Name:BRAVO, HEATHER CRYSTAL
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:CRYSTAL
Last Name:BRAVO
Suffix:
Gender:F
Credentials:
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 161495
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-1495
Mailing Address - Country:US
Mailing Address - Phone:530-305-5315
Mailing Address - Fax:
Practice Address - Street 1:9272 LAGUNA SPRINGS DR BLDG G
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7947
Practice Address - Country:US
Practice Address - Phone:916-691-9980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSY31031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health