Provider Demographics
NPI:1891458030
Name:BRAVO, BRENDA S
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:S
Last Name:BRAVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4544 SAN FERNANDO RD STE 201
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-5015
Mailing Address - Country:US
Mailing Address - Phone:818-240-8843
Mailing Address - Fax:
Practice Address - Street 1:4544 SAN FERNANDO RD STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-5015
Practice Address - Country:US
Practice Address - Phone:818-240-8843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)