Provider Demographics
NPI:1265659254
Name:BRAVO, SANDRA PIKER (LMFT)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:PIKER
Last Name:BRAVO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3141 SAN GABRIEL AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1735
Mailing Address - Country:US
Mailing Address - Phone:818-854-0735
Mailing Address - Fax:
Practice Address - Street 1:4405 W RIVERSIDE DR STE 205
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4050
Practice Address - Country:US
Practice Address - Phone:818-854-0735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC43262106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACBSC677OtherLA DMH PROVIDER
CA00007302Medicaid