Provider Demographics
NPI:1265914329
Name:BRAVO, MELANEY
Entity type:Individual
Prefix:
First Name:MELANEY
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 1:104 E ASHTON BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114-6745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 11TH ST
Practice Address - Street 2:
Practice Address - City:FLORESVILLE
Practice Address - State:TX
Practice Address - Zip Code:78114-2403
Practice Address - Country:US
Practice Address - Phone:830-216-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2063879225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant