Provider Demographics
NPI:1215025887
Name:BRAVO, AWILDA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:AWILDA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10245 67TH RD APT 1T
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2628
Mailing Address - Country:US
Mailing Address - Phone:800-609-4217
Mailing Address - Fax:718-729-2580
Practice Address - Street 1:102-45-67TH ROAD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:800-609-4217
Practice Address - Fax:718-729-2580
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR057682-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical