Provider Demographics
NPI:1275720096
Name:GAVIN, VERONICA BRAVO (MFTI)
Entity Type:Individual
Prefix:MS
First Name:VERONICA
Middle Name:BRAVO
Last Name:GAVIN
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44759 CORTE GUTIERREZ
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-1164
Mailing Address - Country:US
Mailing Address - Phone:951-303-1937
Mailing Address - Fax:
Practice Address - Street 1:6711 ARLINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-1966
Practice Address - Country:US
Practice Address - Phone:951-352-4964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 47022106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist