Provider Demographics
NPI:1760102909
Name:BRAVO, VANESSA TRINA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:TRINA
Last Name:BRAVO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 KINGSMILL DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-2266
Mailing Address - Country:US
Mailing Address - Phone:219-798-2655
Mailing Address - Fax:
Practice Address - Street 1:383 KINGSMILL DR
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2266
Practice Address - Country:US
Practice Address - Phone:219-798-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006848A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty