Provider Demographics
NPI:1891868063
Name:BRAVO PEDIATRIC THERAPIES
Entity Type:Organization
Organization Name:BRAVO PEDIATRIC THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SPEECH PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:773-551-0004
Mailing Address - Street 1:4012 N KOLMAR AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1916
Mailing Address - Country:US
Mailing Address - Phone:773-551-0004
Mailing Address - Fax:773-286-0493
Practice Address - Street 1:4012 N KOLMAR AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1916
Practice Address - Country:US
Practice Address - Phone:773-551-0004
Practice Address - Fax:773-286-0493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01636006OtherBLUE CROSS BLUE SHIELD