Provider Demographics
NPI:1851521017
Name:BRAVO, LISA (MC, LPC, LISAC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:MC, LPC, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 S PRICE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-6607
Mailing Address - Country:US
Mailing Address - Phone:480-540-5193
Mailing Address - Fax:
Practice Address - Street 1:1490 S PRICE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-6607
Practice Address - Country:US
Practice Address - Phone:480-540-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC12442101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional