Provider Demographics
NPI:1700907078
Name:BRAVO, DIANA Y (MS,OTR/L)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:Y
Last Name:BRAVO
Suffix:
Gender:F
Credentials:MS,OTR/L
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:Y
Other - Last Name:ESTRADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:2900 S COMMERCE PKWY
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3622
Mailing Address - Country:US
Mailing Address - Phone:954-385-6281
Mailing Address - Fax:954-385-6289
Practice Address - Street 1:2900 S COMMERCE PKWY
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3622
Practice Address - Country:US
Practice Address - Phone:954-385-6281
Practice Address - Fax:954-385-6289
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 10831225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8902054 00Medicaid