Provider Demographics
NPI:1689429045
Name:BRAVO, SANDRA (LCSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:BRAVO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 LEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2327
Mailing Address - Country:US
Mailing Address - Phone:140-861-3409
Mailing Address - Fax:
Practice Address - Street 1:567 LEIGH AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2327
Practice Address - Country:US
Practice Address - Phone:140-861-3409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1151241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical