Provider Demographics
NPI:1801377312
Name:BRAVO ECHEGOLLEN, ANDREA ELIZABETH (RBT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ELIZABETH
Last Name:BRAVO ECHEGOLLEN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 HEARTLAND DR
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-9466
Mailing Address - Country:US
Mailing Address - Phone:209-342-8413
Mailing Address - Fax:
Practice Address - Street 1:6000 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-6073
Practice Address - Country:US
Practice Address - Phone:916-548-2562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-63294106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician