Provider Demographics
NPI:1346000783
Name:BRAVE SOUL THERAPY, A LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL COR
Entity Type:Organization
Organization Name:BRAVE SOUL THERAPY, A LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL COR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERMLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:408-337-6473
Mailing Address - Street 1:2108 N ST # 9001
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5712
Mailing Address - Country:US
Mailing Address - Phone:408-337-6473
Mailing Address - Fax:
Practice Address - Street 1:245 MCEVOY ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-4807
Practice Address - Country:US
Practice Address - Phone:408-337-6473
Practice Address - Fax:408-352-6906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty