Provider Demographics
NPI:1811520463
Name:TOLEDO-BRAVO, JOHANNA PRISCILA
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:PRISCILA
Last Name:TOLEDO-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 1:28 HARKER AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-2823
Mailing Address - Country:US
Mailing Address - Phone:203-690-9128
Mailing Address - Fax:
Practice Address - Street 1:705 N MOUNTAIN RD STE A101
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-1431
Practice Address - Country:US
Practice Address - Phone:860-233-3033
Practice Address - Fax:858-924-0244
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12259493103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst