Provider Demographics
NPI:1629402227
Name:BRAVO-AVINA, LUIS ENRIQUE
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ENRIQUE
Last Name:BRAVO-AVINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3908
Mailing Address - Country:US
Mailing Address - Phone:707-568-2300
Mailing Address - Fax:
Practice Address - Street 1:1200 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3908
Practice Address - Country:US
Practice Address - Phone:707-568-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor