Provider Demographics
NPI:1356066799
Name:BRAVO, ESTEVAN DAMONE
Entity type:Individual
Prefix:
First Name:ESTEVAN
Middle Name:DAMONE
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 1:29595 PUJOL ST APT 12112
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-6775
Mailing Address - Country:US
Mailing Address - Phone:559-614-2123
Mailing Address - Fax:
Practice Address - Street 1:29595 PUJOL ST APT 12112
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-6775
Practice Address - Country:US
Practice Address - Phone:559-614-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician