Provider Demographics
NPI:1770294183
Name:BRAVO, LIANA
Entity type:Individual
Prefix:
First Name:LIANA
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 1:16510 SW 107TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-2913
Mailing Address - Country:US
Mailing Address - Phone:786-608-1594
Mailing Address - Fax:
Practice Address - Street 1:16510 SW 107TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-2913
Practice Address - Country:US
Practice Address - Phone:786-608-1594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-201276106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician