Provider Demographics
NPI:1225454960
Name:BRAVO-PATINO, SANDRA JULIANA (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JULIANA
Last Name:BRAVO-PATINO
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 1:5231 FREMONT CT SW
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3240
Mailing Address - Country:US
Mailing Address - Phone:678-368-9623
Mailing Address - Fax:
Practice Address - Street 1:5231 FREMONT CT SW
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3240
Practice Address - Country:US
Practice Address - Phone:678-368-9623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0048971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical