Provider Demographics
NPI:1124788195
Name:BRAVO, CORRINA LYNN
Entity type:Individual
Prefix:
First Name:CORRINA
Middle Name:LYNN
Last Name:BRAVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CORRINA
Other - Middle Name:LYNN
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7380 ADRIAN DR APT 1
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-3748
Mailing Address - Country:US
Mailing Address - Phone:415-419-4653
Mailing Address - Fax:
Practice Address - Street 1:7380 ADRIAN DR APT 1
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-3748
Practice Address - Country:US
Practice Address - Phone:415-419-4653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician