Basic Information
| Provider Information | |||||||||
| NPI: | 1295036010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAVO | ||||||||
| FirstName: | ELSA | ||||||||
| MiddleName: | YOMAIRA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, MFT INTERN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRAVO | ||||||||
| OtherFirstName: | ELSA | ||||||||
| OtherMiddleName: | YOMAIRA | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, MFT INTERN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1055 W HENDERSON AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932571490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595561076 | ||||||||
| FaxNumber: | 5597133717 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 W HENDERSON AVE | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932571490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597881200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2010 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 106H00000X | 75099 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 118642 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.