Basic Information
| Provider Information | |||||||||
| NPI: | 1538562749 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAVO | ||||||||
| FirstName: | CARISSA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCALF | ||||||||
| OtherFirstName: | CARISSA | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417343430 | ||||||||
| FaxNumber: | 5417343638 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 BOWER DR | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975013689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417343430 | ||||||||
| FaxNumber: | 5417343638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2014 | ||||||||
| LastUpdateDate: | 04/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 3008 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.