Provider Demographics
NPI: | 1518546480 |
---|---|
Name: | BRAVO COUNSELING & SERVICES LLC |
Entity Type: | Organization |
Organization Name: | BRAVO COUNSELING & SERVICES LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ROBERT |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | HECKROTE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LPC |
Authorized Official - Phone: | 570-394-3380 |
Mailing Address - Street 1: | 1057 LOCKARD RD |
Mailing Address - Street 2: | |
Mailing Address - City: | MUNCY |
Mailing Address - State: | PA |
Mailing Address - Zip Code: | 17756-7936 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 570-394-3380 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1057 LOCKARD RD |
Practice Address - Street 2: | |
Practice Address - City: | MUNCY |
Practice Address - State: | PA |
Practice Address - Zip Code: | 17756-7936 |
Practice Address - Country: | US |
Practice Address - Phone: | 570-394-3380 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-04-06 |
Last Update Date: | 2021-04-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |