Provider Demographics
NPI:1295315133
Name:BRAVO, RALPH LOUIS
Entity type:Individual
Prefix:MR
First Name:RALPH
Middle Name:LOUIS
Last Name:BRAVO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1164 N EASTMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90063-2137
Mailing Address - Country:US
Mailing Address - Phone:310-801-5881
Mailing Address - Fax:
Practice Address - Street 1:417 S HILL ST STE 208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1217
Practice Address - Country:US
Practice Address - Phone:310-801-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-48325103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty