Provider Demographics
NPI:1609288422
Name:BRAVO, MARIA GUADALUPE
Entity type:Individual
Prefix:MS
First Name:MARIA
Middle Name:GUADALUPE
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 1:2550 W CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-4201
Mailing Address - Country:US
Mailing Address - Phone:559-264-7521
Mailing Address - Fax:
Practice Address - Street 1:2550 W CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-4201
Practice Address - Country:US
Practice Address - Phone:559-264-7521
Practice Address - Fax:559-233-0016
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60678104100000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker