Provider Demographics
NPI:1285422881
Name:BRAVE NORTH THERAPY, LCSW, PLLC
Entity type:Organization
Organization Name:BRAVE NORTH THERAPY, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-834-2014
Mailing Address - Street 1:PO BOX 1241
Mailing Address - Street 2:
Mailing Address - City:WEEDSPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13166-1241
Mailing Address - Country:US
Mailing Address - Phone:315-834-2014
Mailing Address - Fax:
Practice Address - Street 1:2693 E. BRUTUS STREET
Practice Address - Street 2:
Practice Address - City:WEEDSPORT
Practice Address - State:NY
Practice Address - Zip Code:13166
Practice Address - Country:US
Practice Address - Phone:315-834-2014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty