1225454960 NPI number — SANDRA JULIANA BRAVO-PATINO LCSW

Table of content: SANDRA JULIANA BRAVO-PATINO LCSW (NPI 1225454960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225454960 NPI number — SANDRA JULIANA BRAVO-PATINO LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAVO-PATINO
Provider First Name:
SANDRA
Provider Middle Name:
JULIANA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225454960
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5231 FREMONT CT SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE MOUNTAIN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30087-3240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-368-9623
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5231 FREMONT CT SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONE MOUNTAIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30087-3240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-368-9623
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CSW004897 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com