Provider Demographics
NPI:1134350564
Name:BRAVO, MELISSA MARIE (LPC)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:BRAVO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6444 FAIRWAY AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-3073
Mailing Address - Country:US
Mailing Address - Phone:971-218-7351
Mailing Address - Fax:971-901-3065
Practice Address - Street 1:6444 FAIRWAY AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-3073
Practice Address - Country:US
Practice Address - Phone:971-901-2731
Practice Address - Fax:971-901-3065
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC3420101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500670439Medicaid