Provider Demographics
NPI:1619301983
Name:BRAVO, DIANNE (MA)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 MAIN ST
Mailing Address - Street 2:614A
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-3040
Mailing Address - Country:US
Mailing Address - Phone:802-881-7586
Mailing Address - Fax:
Practice Address - Street 1:139 MAIN ST
Practice Address - Street 2:614A
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-3040
Practice Address - Country:US
Practice Address - Phone:802-881-7586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
VT097.0107658 ROSTER#106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist