Provider Demographics
NPI:1770180002
Name:BRAVO-LAGUNA, GIANCARLO
Entity Type:Individual
Prefix:
First Name:GIANCARLO
Middle Name:
Last Name:BRAVO-LAGUNA
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 1:7 THEODORE RD
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-2510
Mailing Address - Country:US
Mailing Address - Phone:203-360-1783
Mailing Address - Fax:
Practice Address - Street 1:180 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4252
Practice Address - Country:US
Practice Address - Phone:203-394-6529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2024-03-19
Deactivation Date:2021-04-20
Deactivation Code:
Reactivation Date:2024-03-19
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker