Provider Demographics
NPI:1174027403
Name:BRAVO, SHANNON (ASW)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 I ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-2400
Mailing Address - Country:US
Mailing Address - Phone:916-874-6502
Mailing Address - Fax:
Practice Address - Street 1:651 I ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-2400
Practice Address - Country:US
Practice Address - Phone:916-874-6502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA677031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical