Provider Demographics
NPI:1659647162
Name:BRAVO-GARRIS, MILLIE MARIE (BS)
Entity Type:Individual
Prefix:
First Name:MILLIE
Middle Name:MARIE
Last Name:BRAVO-GARRIS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 WESTLAND ROAD SUITE C
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001
Mailing Address - Country:US
Mailing Address - Phone:307-389-8078
Mailing Address - Fax:
Practice Address - Street 1:202 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1410
Practice Address - Country:US
Practice Address - Phone:307-389-8078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY172V00000X
251C00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No251C00000XAgenciesDay Training, Developmentally Disabled Services