Provider Demographics
NPI:1972907681
Name:BRAVO, DANIELA
Entity Type:Individual
Prefix:
First Name:DANIELA
Middle Name:
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 1:1421 GUERNEVILLE RD STE 218
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-7255
Mailing Address - Country:US
Mailing Address - Phone:707-576-7700
Mailing Address - Fax:707-576-7744
Practice Address - Street 1:1421 GUERNEVILLE RD STE 218
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7255
Practice Address - Country:US
Practice Address - Phone:707-576-7700
Practice Address - Fax:707-576-7744
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA887511041C0700X
253J00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No253J00000XAgenciesFoster Care Agency