Provider Demographics
NPI:1598192619
Name:BRAVO, CAMILLA KATHLYNE (LPCS)
Entity Type:Individual
Prefix:
First Name:CAMILLA
Middle Name:KATHLYNE
Last Name:BRAVO
Suffix:
Gender:F
Credentials:LPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 MILL ST
Mailing Address - Street 2:SUITE PW2213
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-2465
Mailing Address - Country:US
Mailing Address - Phone:864-320-1648
Mailing Address - Fax:
Practice Address - Street 1:250 MILL ST
Practice Address - Street 2:SUITE PW2213
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-2465
Practice Address - Country:US
Practice Address - Phone:864-320-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3829101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC421504Medicaid