Provider Demographics
NPI:1376801993
Name:BRAVO, SANDRA (LPC INTERN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:LPC INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4226 LAKECLIFF DR
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-8611
Mailing Address - Country:US
Mailing Address - Phone:254-537-3123
Mailing Address - Fax:
Practice Address - Street 1:100 E CENTRAL TEXAS EXPY STE 100
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-8509
Practice Address - Country:US
Practice Address - Phone:254-501-3555
Practice Address - Fax:254-501-3554
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69167101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional